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the art and science of brief psychotherapies

the art and science of brief psychotherapies

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El libro pertenece al grupo de cinco textos básicos proyectados por el Comité de Revisión de la Residencia en Psiquiatría, y que está destinado a elaborar y medir las "Competencias Básicas en Psicoterapia" que deben poseer los candidatos al término de su programa de formación en psiquiatría clínica en los Estados Unidos.
El libro pertenece al grupo de cinco textos básicos proyectados por el Comité de Revisión de la Residencia en Psiquiatría, y que está destinado a elaborar y medir las "Competencias Básicas en Psicoterapia" que deben poseer los candidatos al término de su programa de formación en psiquiatría clínica en los Estados Unidos.

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The Art and Science of Brief Psychotherapies
A Practitioner’s Guide

The Art and Science of Brief Psychotherapies
A Practitioner’s Guide

Edited by Mantosh J. Dewan, M.D. Brett N. Steenbarger, Ph.D. Roger P. Greenberg, Ph.D.

Washington, DC London, England

Note: The authors have worked to ensure that all information in this book is accurate at the time of publication and consistent with general psychiatric and medical standards, and that information concerning drug dosages, schedules, and routes of administration is accurate at the time of publication and consistent with standards set by the U.S. Food and Drug Administration and the general medical community. As medical research and practice continue to advance, however, therapeutic standards may change. Moreover, specific situations may require a specific therapeutic response not included in this book. For these reasons and because human and mechanical errors sometimes occur, we recommend that readers follow the advice of physicians directly involved in their care or the care of a member of their family. Books published by American Psychiatric Publishing, Inc., represent the views and opinions of the individual authors and do not necessarily represent the policies and opinions of APPI or the American Psychiatric Association. Copyright © 2004 American Psychiatric Publishing, Inc. ALL RIGHTS RESERVED Manufactured in the United States of America on acid-free paper 08 07 06 05 04 5 4 3 2 1 First Edition Typeset in Adobe’s Berling Roman and Frutiger 55 Roman American Psychiatric Publishing, Inc. 1000 Wilson Boulevard Arlington, VA 22209-3901 www.appi.org Library of Congress Cataloging-in-Publication Data The art and science of brief psychotherapies : a practitioner’s guide / [edited by] Mantosh J. Dewan, Brett N. Steenbarger, Roger P. Greenberg. p. ; cm. Includes bibliographical references and index. ISBN 1-58562-067-X (pbk. : alk. paper) 1. Brief psychotherapy. I. Dewan, Mantosh J. II. Steenbarger, Brett N. III. Greenberg, Roger P. [DNLM: 1. Psychotherapy, Brief—methods. WM 420.5.P5 A784 2004] RC480.55.A78 2004 616.89′14—dc22 2003065593 British Library Cataloguing in Publication Data A CIP record is available from the British Library.

With many thanks to our patients, students, mentors, and families for all they have taught us. Mantosh J. Dewan, M.D. Brett N. Steenbarger, Ph.D. Roger P. Greenberg, Ph.D.

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Ph. . . . . . Beck. . . . . . 3 Brief Behavior Therapy . . . . . . . . . . M. . . . . . .D. . . . .D. . . . . . . . . . . and Mantosh J. . . . .D.D. Ph.. . . . .D. . . .D. and Edna B. .D. . . . . Roger P. 5 Brief Interpersonal Psychotherapy . .D. . . Ph. Bux Jr. . . . . . 51 Elizabeth A. . . . . Ph. . . . . . . . . . . . . . . . . .. ix Introduction to the Core Competencies in Psychotherapy Series . Ph. Ph.Contents Contributors. . . . . . . . . . Hembree. . . . ..D. . . Dewan. . . . and Peter J. . . . . .. . Bieling.. Greenberg. . Steenbarger. . . Deborah Roth. 119 Scott Stuart. . . . . . . . . . 85 Brett N. . . . . M. . . Foa. .. . Ph. . . 4 Solution-Focused Brief Therapy: Doing What Works . . . . . . . . . . Steenbarger. Donald A. . .D. . . . . .. Part I Six Key Brief Psychotherapies 2 Cognitive Therapy: Introduction to Theory and Practice . . Ph. . . . . 1 Brett N.D. 15 Judith S. . . . . . . . . xiii 1 Introduction . Ph. . . . . . .

.. Ph. . . . .. . . 9 Brief Psychotherapy in a Multicultural Context . . . . Dewan. . . . . Part II Special Topics 8 Essential Ingredients for Successful Psychotherapy: Effect of Common Factors . . . Sullivan.D. . M. . . Greenberg. . . . . . . M. . Ph. M. Ph. . . Dewan. . . . . . Part III Overview and Synthesis 12 Doing Therapy. . . .D. . . Ph. Steenbarger. and Joël Núñez. . Baucom. . . . Briefly: Overview and Synthesis . . . . Dewan. . .D. . . M. . . . . . Ph. .D..D. .. . . . 243 Rubén J. . . . . . Ph. . . . . 7 Brief Couple Therapy . 10 Combining Brief Psychotherapy and Medications . . . . .. . . and Mantosh J. . . . 257 Mantosh J. . . . . . . .D. 293 . . . . . . . Ph. Bernard Beitman. 189 Donald H. . . . . . . . . and Mantosh J.A. . .6 Time-Limited Dynamic Psychotherapy: Formulation and Intervention. . . .. 231 Roger P. 279 Brett N. . .D. . . . .D. . . M. . . . .D.D. and Laura J. . .D. . . . . . .D. Echemendía. . Index . . Roger P. . M. . . . . . . 157 Hanna Levenson. Epstein. 265 John Manring. . . 11 Evaluating Competence in Brief Psychotherapy . . . . .D. . . . . Greenberg. . Ph. . . . . . . . . .. . . Norman B.

Department of Psychiatry and Behavioral Neurosciences. New York ix .D. Department of Psychology. University of Missouri.D. McMaster University. University of Pennsylvania. Baucom.D. Department of Psychiatry and Neurology.. Columbia University. Beck Institute for Cognitive Therapy and Research. New York. and Director.Contributors Donald H. Canada Donald A. Clinical Associate Professor of Psychology in Psychiatry. Philadelphia. M. Professor and Chair. Bieling. Research Associate. Pennsylvania Bernard Beitman. Bux Jr. Hamilton. Ontario. Ph. Ph. Assistant Professor. Professor and Director.D. Ph. National Center on Addiction and Substance Abuse. Missouri Peter J. Chapel Hill. Ph. University of North Carolina. Beck. Columbia.D. North Carolina Judith S.

Pennsylvania Hanna Levenson. California John Manring. State University of New York. California Pacific Medical Center. Upstate Medical University. Department of Psychiatry. Pennsylvania Roger P. Department of Psychiatry. M. The Psychological Clinic. Ph. Pennsylvania State University. University of Pennsylvania. University of Maryland. Graduate student. Pennsylvania State University. Maryland Edna B. Ph. Department of Psychology. Professor and Director. Pennsylvania Norman B.x The Art and Science of Brief Psychotherapies Mantosh J. Epstein. Brief Psychotherapy Program. Department of Psychology. College Park. University of Pennsylvania. Ph. Professor and Head. Associate Professor and Director. Syracuse. Department of Psychiatry and Behavioral Sciences.D. Upstate Medical University. and Director. Pennsylvania . New York Elizabeth A. Department of Psychiatry. Philadelphia. San Francisco. Director. Department of Psychiatry and Behavioral Sciences.D.D. Ph. Center for the Treatment and Study of Anxiety.D. New York Joël Núñez. University Park.D. Ph. Syracuse. Assistant Professor. Upstate Medical University. University Park.D. Greenberg. M.D. Department of Family Studies.D. Residency Training Program. Center for the Treatment and Study of Anxiety. Director. Dewan.D. Psychology Division. State University of New York. Ph. Professor and Chair. Hembree. Professor. Syracuse. Echemendía. Foa. State University of New York. Ph. Levenson Institute for Training. Department of Psychiatry and Behavioral Sciences. New York Rubén J. Philadelphia.

D. Chapel Hill. Philadelphia. Upstate Medical University. University of North Carolina. M. Iowa Laura J. State University of New York. Sullivan. Department of Psychiatry. Pennsylvania Brett N.D. Steenbarger.Contributors xi Deborah Roth.D. M. Assistant Professor. Department of Psychiatry. Department of Psychiatry and Behavioral Sciences. Department of Psychology. New York Scott Stuart. Ph. Syracuse. Graduate student. Center for the Treatment and Study of Anxiety. University of Iowa.A. Ph. Associate Professor. University of Pennsylvania. Iowa Depression and Clinical Research Center. North Carolina . Iowa City. Associate Professor and Co-Director.

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This shift in emphasis has been compounded by the common practice in our managed care era of “split treatment. Many residents and educators have decried the loss of the “mind” in the increasing emphasis on the biological basis of mental illness and the shift toward somatic treatments as the central therapeutic strategy in psychiatry. however. This shift in emphasis has created considerable concern among both psychiatric educators and the consumers of psychiatric education—the residents themselves. while the psychotherapy is conducted by a mental health professional from another discipline. some psychiatric training programs have deemphasized psychotherapy education.Introduction to the Core Competencies in Psychotherapy Series With the extraordinary progress in the neurosciences and psychopharmacology in recent years. In 1999 both the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) recognized that a set of organizing principles was necessary to measure competence in medical education. as a result of the widespread movement toward the establishment of core competencies throughout all medical specialties.” meaning that psychiatrists are often relegated to seeing the patient for a brief medication management session. These six principles—patient xiii . The importance of psychotherapy in the training of psychiatrists has recently been reaffirmed.

The basic understanding of what is meant by core competencies will be evolving over the next few years as various groups within medicine and psychiatry strive to articulate reasonable standards for educators. All educational projects. brief psychotherapy. The inherent ambiguity of a term like “competence” has sparked much discussion among psychiatric educators. Each volume covers the key principles of practice in the . the Psychiatry Residency Review Committee (RRC) mandated that all psychiatric residency training programs must begin implementing the six core competencies in clinical and didactic curricula. supportive psychotherapy. and systems-based practice—are now collectively referred to as the core competencies in medical education. interpersonal and communication skills. Robert Hales. As of July 2002. and psychotherapy combined with psychopharmacology—should be an outcome of a good psychiatric education for all psychiatric residents. practicebased learning and improvement. As part of the process of adapting the core competencies to psychiatry.xiv The Art and Science of Brief Psychotherapies care. This mandate also requires training directors to develop more sophisticated means of evaluating the progress and learning of residents in their programs. including those involving accreditation. the Psychiatry RRC felt that reasonable competence in five different forms of psychotherapy—long-term psychodynamic psychotherapy. Those entrusted with the training of physicians were no exception.. cognitive behavioral psychotherapy. medical knowledge. So in 2002 Dr. had to develop outcome measures. editor-in-chief at American Psychiatric Publishing. professionalism. appointed me to be the series editor of a new line of five books. Like all medical specialties. felt that the publication of basic texts in each of the five mandated areas would be of great value to training programs. Those programs that fail to do so may receive citations when they undergo accreditation surveys. Does the term mean that practitioners are sufficiently skilled that one would refer a family member to them for treatment without hesitation? Or does the term imply rudimentary knowledge and practice that would ensure a reasonable degree of safety? These questions are not yet fully resolved. This series is titled Core Competencies in Psychotherapy and features five brief texts by leading experts in each of the psychotherapies. Inc.S. Department of Education approximately 20 years ago. Many training programs have had to scramble to find faculty who are well trained in these modalities and teaching materials to facilitate the learning process. American Psychiatric Publishing. psychiatry has risen to the occasion by making attempts to translate the notion of core competencies into meaningful psychiatric terms. This movement within medical education was a direct consequence of a broader movement launched by the U.

org. However. ultimately. classroom teaching.) True expertise in psychotherapy requires many years of experience with skilled supervision and consultation. (For more information about the books in this series and their availability. Gabbard.appi. These books will be valuable adjuncts to the traditional methods of psychotherapy education: supervision. Baylor Psychiatry Clinic Baylor College of Medicine Houston. and clinical experience with a variety of patients. the compassionate care of patients who come to us for help. Texas .. Glen O. please visit www. the basic tools can be learned during residency training so that freshly minted psychiatrists are prepared to deliver necessary treatments to the broad range of patients they encounter. Series Editor Brown Foundation Chair of Psychoanalysis Professor of Psychiatry Director of Psychotherapy Education Director. We feel confident that mastery of the material in these five volumes will constitute a major step in the acquisition of competency in psychotherapy and.D. M.Introduction to the Core Competencies in Psychotherapy Series xv treatment and also suggests ways to evaluate whether residents have been trained to a level of competence in each of the therapies.

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We hope that the following chapters provide you with a working sense of brief therapy as a whole: its science and its artistry. Roger P.D. How many times have we heard trainees in the mental health professions assert that they knew the theory but wanted guidance about what to do in the therapy room? In soliciting contributions from our authors. Our goal goes beyond a mere compilation of approaches. Necessity spurring invention. Steenbarger. Ph. Dewan. Mantosh J. or more than a decade.1 Introduction Brett N.D. you will learn about six eminently teachable and learnable models of brief psychotherapy and issues pertinent to their application.D. we decided to pool our efforts and bridge this gap. In this book. We wanted to 1 F . we have taught and supervised psychiatry residents and predoctoral interns in clinical psychology in the practice of the brief psychotherapies. we challenged them to provide such practical guidance. we lamented the absence of a single book that could guide the developing practitioner in learning the core concepts and skills of short-term work. M. Greenberg. Ph. Throughout that time.

emphasizing those that have found empirical support in the research literature and that can be readily learned. New York. solution-focused. We believe the authors have admirably shown that the practice of brief therapy is much more than the application of intuitively applied guidelines. Why Brief Therapy? Never before in the history of psychotherapy have therapists been asked to do so much. we have selected a set of authors who are intimately involved in the teaching and training of brief therapy and who are uniquely qualified to supply readers with hands-on information about the practice of their chosen approaches. and couple therapies. Syracuse. This means that our goal differs from that of many texts. Whether you are a beginning therapist wishing to learn more about brief therapy or an experienced clinician looking to expand your repertoire. It has been our experience as educators that beginning with highly structured therapies is useful and reassuring to new therapists. behavior.2 The Art and Science of Brief Psychotherapies provide not only a book about brief therapy but also a guide to doing brief work. Limited time and finan- . We present these models in the order that we have taught the brief therapies in the Department of Psychiatry and Behavioral Sciences at Upstate Medical University. Rather. clinic. Indeed. Once they have internalized these structures. Our task as editors has been to supplement their how-to expertise by highlighting the common themes behind the various chapters. we sought to cover a variety of short-term models. and hospital settings. We are not attempting to review all literature pertinent to short-term work. these modalities provide invaluable tools for handling the most common presenting concerns in private practice. interpersonal. counseling centers. In making this selection. providing readers with overarching principles and techniques to draw on in their own practice. they feel more prepared to deviate from the manuals and make the improvisations that are necessary in the more fluid psychodynamic and couple therapies. surveys suggest that more than three-quarters of all therapists are conducting planned brief therapy and that such short-term work accounts for 40% of their clinical hours (Levenson 1995). and hospitals—and especially among insurers— have guaranteed that most psychotherapy is swift and targeted. for more than a decade: cognitive. Together. Tight economic conditions in community clinics. so quickly. nor are we making any effort to cover all of the many schools of brief therapy in current use. time-limited dynamic. we think you will find the chapters in this book to be excellent starting points.

As time frames for intervention narrow. Furthermore. A common refrain in the practice literature is the role of therapist activity in short-term work. anxiety. it almost certainly will include brief therapy. Many trainees tell us that they find such work particularly rewarding because it challenges them to make the most of each session and draw on novel strategies for dislodging problem patterns and instilling promising new ones. This variety lends spice to the daily challenge of helping people change their lives. There are other reasons for developing knowledge and skills in brief work. One of the most important is that short-term therapies are proven effective in treating a wide range of emotional disorders (Barlow 2001. 2001). This has been shown in studies of behavior therapy for obsessive-compulsive disorder and with interpersonal therapy for depression (Baxter et al. mood. the therapist assumes a more hands-on. brief therapies not only treat symptoms and dysfunction as effectively as medications but also change brain function in a comparable manner. As several authors have observed. A third. including cognitive. the average number of sessions per client1 tends to fall within parameters recognized as brief (Steenbarger and Budman 1998). 1992. and more personal. as well as efficacious. even when the number of sessions is not limited by clinic policies or insurance constraints. Koss and Shiang 1994. Brody et al.Introduction 3 cial resources among patients also help to ensure that much therapy is brief. active stance in catalyzing change. interpersonal. assigning homework tasks. and the points at which outcomes are assessed—it nonetheless seems clear that many adjustment. Indeed. the vast majority of outcome studies in psychotherapy have been conducted with short-term interventions. and teaching coping skills. and strategic. reason for learning brief therapy is that it opens the door to creative. behavioral. creating therapeutic experiences within sessions. 1 . the patient population. however. the terms patient and client will be used interchangeably in this chapter. Dewan and Pies 2001. and relationship problems can be successfully treated with brief therapy (Steenbarger 1994). Steenbarger 1992). This frequently entails reframing presenting issues. making most of the literature a literature on brief therapy outcomes. Although the trajectory for change over time hinges on a variety of variables—including the outcome measures used. If your clinical practice will include psychotherapy. ways of assisting individuals and couples. It is not unusual for a brief therapist to integrate interventions drawn from many approaches. In deference to the fact that people seeking therapeutic assistance do so in both medical and nonmedical settings.

rather than adherence to a session limit. .4 The Art and Science of Brief Psychotherapies What Is Brief Therapy? Defining brief therapy is every bit as difficult as conducting it. The therapist takes responsibility for actively maintaining this focus and ensuring that it is a mutual one. A 20-session course of treatment for a client with a personality disorder may be more time-effective than a 10-session course of therapy for an adjustment concern. placing the responsibility on the therapist to screen individuals before initiating short-term work. In short. The intent and orientation of the therapist. Adding to the confusion. it may make greater sense to define brevity by clinician intent rather than by an absolute number of sessions. with planned strategies for accelerating change. Some elements in this intent include • Planning—Short-term work is brief by design rather than by default (Budman and Gurman 1988). would make all therapy brief! A further dilemma occurs when sessions are distributed intermittently. characterize brevity. by some definitions. • Focus—The clinician and client seek focused changes in short-term work rather than broad personality change. placing the therapist in the role of actively stimulating and encouraging change. The brevity of behavior therapy—often concluding in fewer than 10 sessions—is not the brevity of cognitive restructuring work. • Patient selection—As we will see later in this chapter. which. Health maintenance organization plans typically limit the mental health benefit to 20 outpatient sessions annually. allowing for extended time between sessions to rehearse skills and consolidate changes. we can think of interventions falling within the broad designation of brief therapy when time is an explicit consideration in treatment planning (Steenbarger 2002). which frequently extends from 10 to 20 sessions. • Efficiency—The goal of the brief therapist is time-effectiveness: efficiency in achieving a particular set of objectives (Budman 1994). brief therapy is not appropriate for all patients and disorders. Is such work brief or long-term? For all of these reasons. we commonly find short-term psychodynamic therapies lasting 20 sessions or more and solution-focused treatments lasting 3 or fewer sessions. It is not unusual for brief therapists to hold fewer than 10 sessions with a patient spaced out over a 12-month period.

Understanding—Brief therapy tends to be most helpful for patients who have a clear understanding of their problems and a strong motivation to address these. As a result. Although social support is a necessary and legitimate . Interpersonal history—For therapy to proceed time-effectively. Social support—Many clients enter therapy not only to make changes in their personal and interpersonal lives but also to obtain ongoing social support. Such severity often also interferes with the individual’s ability to actively use therapeutic strategies between sessions. it may take many sessions before adequate trust and disclosure can develop. Complexity—A highly complex presenting concern. short-term work indicates several potential indications and contraindications (Steenbarger 1994. 5. they may require many weeks of exploratory therapy and self-discovery before they are ready to make a commitment to more action-oriented. being unclear about the changes they need to make. 2. shortterm approaches. Often. extending the duration of treatment. or violence. Some of these include 1.Introduction 5 When Is It Appropriate to Conduct Brief Therapy? A review of the practice of. 2002. 6. Duration of the presenting problem—When a problem pattern is chronic. it has been overlearned and often will require more extensive intervention than a pattern that is recent and situational. a key element in accelerating change. For instance. as well as research on. Steenbarger and Budman 1998). a client who presents with an eating disorder may be abusing drugs and alcohol and experiencing symptoms of depression. a rapid alliance between therapist and patient is a necessity. one that has many symptomatic manifestations. In situations in which people’s readiness to change is low (Prochaska et al. or having ambivalence over the need for change. such complex presentations require a combination of helping approaches—psychotherapeutic and psychopharmacological—to address each of the problem components. 1994). often requires more extensive intervention than highly focal problem patterns. 3. 4. they enter therapy denying the need for change. This is particularly true of individuals who are socially isolated because of a lack of social skills and/or fears of rejection and abandonment. Severity of the presenting problem—A severe disorder is one that interferes with many aspects of the client’s life. neglect. If the client’s interpersonal history includes significant incidents of abuse.

complex. These six criteria. Successful and enthusiastic completion of an initial in-session or homework task is an excellent prognostic sign for compliance with the demands of short-term work. and relationship conflicts. represent a useful heuristic for trainees first learning the brief psychotherapies. for example—are frequently ad- . and severe disorders with a series of targeted brief therapies rather than single. skills training for reducing suicidal behaviors and behaviors that interfere with therapy and quality of life may be followed by exposure-based strategies for reducing posttraumatic stress and cognitive work for resolving life problems and increasing self-respect. Because the brief therapies require a high degree of activity for both parties. each of which addresses a particular facet of a syndrome. That having been said. even as part of longer-term intervention. Whereas the presence of any single factor may not preclude short-term work. By stringing together brief therapies with specific targets. anxiety. situations requiring extensive support will necessarily preclude highly abbreviated courses of treatment. ongoing long-term treatments. short-term work.6 The Art and Science of Brief Psychotherapies end of psychotherapy. Thanks to pioneering work on cognitive-behavioral therapy with borderline patients (Linehan et al. it is generally helpful to assess the ability and willingness of the patient to engage in such hands-on efforts at change. there is increased interest in treating chronic. even as they rehearse coping strategies. 2001). clients who are particularly sensitive to interpersonal loss may find it impossible to tolerate a therapy in which a working bond is quickly dissolved. An initial set of experiential exercises and/or homework assignments is often an effective way of determining a client’s appropriateness for active. for instance. which form the acronym DISCUS. Many brief modalities require individuals to reexperience their problems. This may be more than some can or wish to tolerate. The presence of multiple DISCUS criteria at client intake is almost certain to identify a situation in which highly abbreviated treatment will raise the odds of future relapse (Steenbarger 1994). shortterm work becomes useful with even the most challenging patient populations. grief. In Linehan’s work. such presence often will require longer-term intervention within the range of treatments normally associated with brevity. Indeed. The briefest of the brief therapies—solution-focused and behavioral approaches—are often used for focal problems of adjustment. Longer-standing and more pervasive concerns—depression and eating disorders. we note that brief therapeutic strategies are finding wide application to chronically ill populations.

once an agreement is reached as to the means and ends of therapy. the brief therapist takes an active role in both evoking client patterns and introducing ways of interrupting and modifying these. however. brief therapy is not wholly different from time-unlimited treatment. just as lightning chess is closely allied to its traditional counterpart. framing treatment approaches and goals in ways that can be readily assimilated by the client. If brief therapy truly is an intensification of change processes found in all of the empirically supported therapies. with both client and clinician taking active roles in navigating change. At its best. to be especially helpful for trainees learning short-term work (Steenbarger 1992. Perhaps the greatest shift of mind-set that helps to abbreviate the change process is the therapist’s assumption of responsibility for making things happen in brief therapy. is that brief therapies owe their brevity to an intensification of the elements that facilitate change in all psychotherapies (Steenbarger 1992. nondirective brief therapy is an oxymoron. doing brief work can feel quite different from undertaking longer-term therapy. Shorn of the luxury of time to work through client resistances and historical antecedents of current problems. grounded in the process and outcome literatures of psychotherapy. What Makes Brief Therapies Brief? A major theme in this book. which we elaborate in Chapter 12.2 then our first question becomes “How do people change in any therapy?” We have found a schematic of the change process. Moreover. When brief methods are brought to bear on the most chronic and severe problems—including personality disorders—they are generally components of longer-term treatment or modules within overarching treatment and rehabilitation plans. the short-term clinician actively avoids resistance by maximizing the alliance. For the therapist. Steenbarger 2 We would further submit that therapy itself is an intensification of the change processes encountered in everyday life. .Introduction 7 dressed by the lengthier of the brief schools. it is difficult to find disorders for which short-term methods do not have value. In a very important sense. Steenbarger and Budman 1998). short-term work is a copiloting. Although not all problems can be solved briefly. much as the experience of driving laps in a race car differs from the experience of regular open-highway driving. In other words. such as cognitive restructuring and short-term dynamic therapy.

as in chess. Discrepancy—In therapy. feeling. interpersonal. Some emphasize interactions with the therapist as a primary locus of change efforts. Some tend to define broader treatment goals. and relating to others. This can entail repeated application of the new insights. a search for patterns among the presenting concerns. behaving. and emotional repertoire. others use more targeted. including situations encountered in the therapy office. feeling. 2. it appears. brief therapists afflict the comfort of their clients. and interacting. In the middle phase of therapy. Some focus more on the present.8 The Art and Science of Brief Psychotherapies and Budman 1998). and a creation of a treatment plan to address these patterns. This schematic emphasizes three phases of therapeutic change: 1. whereas others focus on the past and present. discrepant modes of thinking. 3. what makes the different approaches to therapy unique is their implementation of these three phases. and experiences to daily-life situations. . maladaptive client patterns that appear in their daily lives and/or in their therapy sessions become a focus for change. As we shall see in Chapter 12. focal ones. the patient is able to internalize and maintain a new behavioral. Engagement—This opening phase of therapy features a development of a favorable working alliance between therapist and patient. Consolidation—Once the client recognizes his or her maladaptive patterns and identifies promising new. Once in this heightened state. a ventilation of client concerns and gathering of information by the clinician. giving way to a more freely flowing mid-game. In “working through” past patterns and finding constructive replacements. others stress out-of-session experiences. the opening moves tend to be highly circumscribed. the goal of therapy becomes a consolidation of these new patterns. Brief therapy. Identifying this common process underlying all therapies helps us understand what brief therapists do to help abbreviate treatment. constructive ways of thinking and behaving that are discrepant from these maladaptive patterns and encourages their exploration and possible adoption. The therapist aids in the discovery of new. 1993). heightening their emotional experience. individuals are more open to processing new ways of thinking. we submit that the various schools of short-term work simply represent different means to the same end: accelerated learning in nonordinary states of awareness (Steenbarger 2002). Indeed. takes advantage of the fact that learning under emotional circumstances is more enduring than learning tackled in ordinary states of experiencing (Greenberg et al. skills. By actively evoking problem patterns.

You will be able to read about the therapies and why particular interventions are used. Trial interventions under carefully controlled. do one. we might modify the formulation to “read one. challenging those old patterns and juxtaposing them with promising alternatives. Prudent adherence to the indications and contraindications of brief work will ensure the best outcomes for all patients. not challenges to those already present. We. too. How Can Brief Therapy Be Learned? A classic prescription for medical education is “see one. see-one experience to jump in and do one. You will also be able to see how those approaches are implemented through illustrative case material. in-session conditions. and free from chronic and severe symptoms that would interfere with the ability to sustain change efforts. A good book on therapy—like good supervision— needs to provide elements of discrepancy and consolidation.Introduction 9 This formulation helps to explain why brief work is not appropriate for some clients. Finally. come to our profession with patterns. do one. In an important sense. They may require supportive interventions that build defenses. and sometimes these prove limiting. A careful history at the outset of therapy is essential to discriminate between those clients who can benefit from an afflicting of their comfort and those who require comfort from their afflictions.” In the case of acquiring competence in brief therapy. teach one. Outcomes in any kind of therapy are most likely to be rapid and favorable if clients are motivated for change. the change process for therapists is no different from that among patients. and specialized readings and videotapes. The idea is to describe not only what to do but also why to do it. see one. practitioners with considerable experience in training mental health professionals in brief work will take you through their favored approaches step by step. our hope is that they will provide a solid foundation for further training efforts: workshops. can be useful in ascertaining the degree to which brief work is likely to be helpful or harmful. direct supervision. such as guided imagery exercises in which a patient must evoke a recent troubling event. we would be remiss if we did not point out that brief therapy is often brief precisely because of patient selection criteria that are typically used. As . Individuals at risk for regression and decompensation in the face of stress may not tolerate the elicitation of symptoms that is key to brevity. Although individual chapters may not always provide enough readone. actively engaged with their therapists.” In the chapters that follow. so that you can start thinking like a brief therapist in your own work.

Shiang J: Research on brief psychotherapy. pp 470–522 . The discrepancy may prove jarring at first. Then examine how the authors proceeded and how their work differs from your own. References Barlow DH: Clinical Handbook of Psychological Disorders: A Step-by-Step Treatment Manual. supervision—you will start to think differently about your clinical work. Guilford. it is a distillation and an intensification of what has worked all along. New York. 3rd Edition. 1994. 2001. in Handbook of Psychotherapy and Behavior Change. pp 664–700 Levenson H: Time-Limited Dynamic Psychotherapy: A Guide to Clinical Practice. 2001 Baxter LR. Formerly foreign thoughts will creep into your mind. DC. Stoessel P. and there is a science. We hope that these chapters are a useful starting point in learning both. New York. 2001 Budman SH: Treating Time Effectively. Brief treatment is not less of the same. Pies RW (eds): The Difficult-to-Treat Psychiatric Patient. To date. 2001 Greenberg LS. but it also may open the door to new ways of thinking about and responding to your clients. requiring the consistent efforts of both parties. practitioners have relied perhaps too much on talking as a sole source of cure. American Psychiatric Press. try to think through how you would normally tackle such cases. Basic Books. Arch Gen Psychiatry 58:631–640. observation. New York. With enough exposure—book reading. 1993 Koss MP. Washington. 1994 Budman SH. Garfield SL. Gurman AS: Theory and Practice of Brief Therapy. 1992 Brody AL. 1995 Linehan MM. New York. Saxena S. Cochran BN. Edited by Barlow DH. People change by doing things differently and by internalizing those experiences. New York. et al: Regional brain metabolic changes in patients with major depression treated with either paroxetine or interpersonal therapy: preliminary findings. et al: Caudate glucose metabolic rate changes with both drug and behavior therapy for obsessive-compulsive disorder. Guilford. Recognition of the ways in which we can catalyze change has the potential to invigorate our work and extend our repertoire. Kehrer CA: Dialectical behavior therapy for borderline personality disorder. Bergman KS. Rice LN. Schwartz JM. 3rd Edition. Wiley. New York. 4th Edition. 1988 Dewan MJ. Guilford. Guilford. Edited by Bergin AE. therapy will always be a joint enterprise. There is an art to working briefly.10 The Art and Science of Brief Psychotherapies you read through the various case histories and examples. Elliott R: Facilitating Emotional Change: The Momentby-Moment Process. such as “How can I make this happen?” To be sure. New York. Guilford. however. in Clinical Handbook of Psychological Disorders. Arch Gen Psychiatry 49:681–689.

Prof Psychol Res Pr 25:111–119. The Counseling Psychologist 20:403–450. Norcross JC. in Psychologists’ Desk Reference. New York. Norcross JC. 1994 Steenbarger BN: Brief therapy. pp 283–287 . Avon. Hill SS. Oxford University Press. New York. 2002. Elsevier. Sledge W. 1998.Introduction 11 Prochaska JO. Budman SH: Principles of brief and time-effective therapies. DiClemente CC: Changing for Good. pp 349–358 Steenbarger BN. 1994 Steenbarger BN: Toward science-practice integration in brief counseling and therapy. Edited by Hersen M. Edited by Koocher GP. New York. 1992 Steenbarger BN: Duration and outcome in psychotherapy: an integrative review. in Encyclopedia of Psychotherapy.

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Part I Six Key Brief Psychotherapies .

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2 Cognitive Therapy Introduction to Theory and Practice Judith S. cancer. Peter J. It has been extended to and studied for adolescents and children.D. noncardiac chest pain.D. Ph. posttraumatic stress disorder. post–myocardial infarction depression. and other chronic pain conditions (White and Freeman 2000). and substance abuse. obsessive-compulsive disorder. couples. hypertension. migraine. Beck. fibromyalgia. 15 C . Beck and Weishaar 2000). and families (A. ognitive therapy is an empirically validated form of brief psychotherapy that has been shown to be effective in more than 350 outcome studies for a myriad of psychiatric disorders. Several studies have documented its effectiveness as an adjunctive treatment to medication for serious mental disorders such as bipolar disorder and schizophrenia. social phobia. Bieling. panic. Ph.T. including depression. bulimia. It also has been applied and found effective in the treatment of medical disorders such as chronic fatigue syndrome. diabetes. It is currently being tested for personality disorders as well. generalized anxiety disorder.

Several cognitive therapy training centers have been established around the world. conceptualization of individual patients. used throughout the chapter. the theory is based. In fact. According to A. Alexander. Beck and Weishaar (2000). in part. cognitive therapy has seen tremendous interest and growth. we examine the roots of cognitive therapy. Depression and anxiety disorders are emphasized. to find empirical support for the theory that depression resulted from inner-directed or retroflected anger. . Beck had trained in and practiced psychoanalysis. and a case example. with an operationalized treatment based on an elaborate and empirically supported theory of psychopathology. In the late 1950s and early 1960s. developed cognitive therapy in the mid-1960s. M. including Adler. is elaborated on at the end of the chapter. Horney. This approach emphasizes the role of individuals’ views of themselves and their personal worlds as being central to their behavioral reactions. and common techniques. Kelly’s description of individuals’ personal constructs and beliefs helped shape cognitive theory. The cognitive model of psychological functioning and psychopathology is described to provide the reader with a theoretical foundation for understanding principles of therapy. Origins of Cognitive Therapy Cognitive therapy is a short-term structured therapy that uses an information-processing model as the key to understanding and ameliorating psychopathological conditions. he conducted a series of experimental studies that he predicted would support psychoanalytic constructs but found the opposite to be true.. Beck.D.16 The Art and Science of Brief Psychotherapies Aaron T. treatment planning. Cognitive therapy is a comprehensive system of psychotherapy. Since that time. and the Academy of Cognitive Therapy has been formed to certify individuals as cognitive therapists. case formulation. psychiatric residents in the United States are required to show competence in cognitive therapy. As of 2001. on a phenomenological approach to psychology. In this chapter. as did Arnold’s and Lazarus’s cognitive theories of emotion. The first cognitive therapy outcome study of unipolar depression was published in 1977. describing its origin and its theory of psychiatric disturbance. He failed. as espoused by Epictetus and other Greek Stoic philosophers and more contemporary theorists. general strategies. T. The identification of cognition as the critical element in psychopathology was a revolutionary view in the 1960s because psychoanalytic theory and therapy dominated the treatment of psychopathology at the time. and Sullivan. for example.

Lewinsohn. their worlds. “I can’t do anything right. A returned to her apartment after work. Mahoney. physiological arousal is also decreased. I’ll never get my act together” [automatic thoughts]. I can’t believe I did that. When she arrived late at work one day (an infrequent occurrence). she thought. and Meichenbaum were influential. A. without even taking off her coat [behavior] (Figure 2–1). many of their perceptions are incorrect and dysfunctional to some degree. T. “I’m so stupid. a depressed woman. “I’m a total basket case. When individuals are distressed. whose rational-emotive therapy posited that irrational beliefs were the basis of psychological dysfunction. Theorists such as Bandura. Beck also was influenced by the other prevailing school of psychology at the time: behaviorism. and self-control therapy.Cognitive Therapy 17 Through further experimentation and a great deal of clinical observation. Cognitive Theory of Psychopathology At the most superficial level. Then she lay down on the sofa. individuals show characteristic patterns or themes in their thinking. The following vignette illustrates the cognitive model: Almost every day when Ms. She had numerous distorted thoughts that led to sad. She felt very sad [emotion] and heavy in her body [physiological reaction]. they can correct their thinking so that it more closely resembles reality. particularly their negative thoughts about themselves. stress inoculation training. they generally feel better and behave more functionally. and noticed the disarray [situation]. Beck (1963). the cognitive model states that people’s perceptions or spontaneous thoughts about situations influence their emotional and behavioral (and often physiological) reactions. she thought. will be used throughout this chapter as a case example. By learning to identify and evaluate their spontaneously occurring thoughts. and their futures. opened the door. Ms. Beck drew on the work of many other influential theorists. he began to conclude that a key element in depression was the negatively biased judgments patients had of themselves. as were the burgeoning behavioral and cognitive-behavioral approaches: social learning.” When her kitchen sink . problem-solving training. she thought. hopeless feelings and dysfunctional behavior. including Ellis. The idea of helplessness and inadequacy was prominent in Ms.” When she discovered a bill she had forgotten to pay. When patients do so. A’s perceptions. Especially in patients with anxiety. According to A.

18 The Art and Science of Brief Psychotherapies Situation Sees disarray in apartment Automatic thoughts I’m a total basket case. I’ll never get my act together. leaked. She distorted reality by processing information in light of this belief. she thought. A had a basic or core belief: “I am helpless and inadequate. each with a somewhat different nuance. bad. Some patients hold beliefs in both categories. In a psychopathological state. vulnerable. The cognitive model. out of control. unworthy. Helpless beliefs are expressed in various ways. who were psychologically healthy before the onset of their disorder. Patients with a belief that they are unlovable may state that they are defective. individuals typically hold negative core beliefs about themselves that fall into one of two broad categories: those related to helplessness and those related to unlovability (J. “I don’t know what to do. or inferior in achievement. see Table 2–1). may have . ineffective. weak. interpreting even neutral situations negatively and ignoring or discounting (positive) evidence to the contrary. Emotion Sadness Physiological reaction Heaviness in body Behavior Lies down with coat on Figure 2–1. Beck 1995.” This belief shaped her perception of her experience.” It was apparent that Ms. Patients may believe that they are powerless. Patients with straightforward depression and anxiety disorders.S. or likely to be rejected and abandoned.

A believed so strongly that she was inadequate.S.. that she was generally an adequate child who was being told she had to accomplish unreasonably difficult tasks). Categories of core beliefs Helpless I am incompetent. Unlovable I am unlikable. I am vulnerable. “I am reasonably adequate”. Adapted from J. A series of experiences such as these at home. I am out of control. Whenever her belief of incapability was activated. I’m not good enough (so I won’t be loved). “I am reasonably lovable. (I don’t measure up. A had a series of automatic thoughts with that theme. I am worthless (because I don’t produce). I am worthless (so I won’t be loved). led to the development of her negative belief. A had significant traits of dependence. at times. to see herself as inadequate. Beck 1997). I am defective.”) Their negative beliefs may be activated only during the course of their disorder. I am weak.) I’m not good enough. Because Ms. I am a failure. Beck 1995. I am powerless. Soon she became hypervigilant for perceived signs of inadequacy and began. She was often expected to perform tasks that were beyond her developmental capability. others. and their worlds. I am inferior. A believed that she was . I am evil. I will be abandoned. of course. I am defective (so I won’t be loved).Cognitive Therapy 19 Table 2–1.S. may have had negative beliefs activated more or less continuously throughout their lives. Negative beliefs about the self in Axis II patients usually originated in developmental experiences in which the child negatively construed events relevant to himself or herself (J. I am ugly. she began to act inadequately at times. I will be rejected. I am different. as well as a slight learning disability that hindered her achievement at school. had relatively positive or benign beliefs about themselves throughout their lives (e. As she was growing up as a young adolescent and adult. Ms. She began to view herself as inadequate (not recognizing. Ms. Patients with personality disorders. There is something wrong with me (so I won’t be loved). I am bad. Because Ms.) Source. (I don’t measure up. These thoughts affected her not only emotionally and physiologically but also behaviorally. in contrast.g. even when she clearly was not. Patients’ dysfunctional reactions to situations make sense given how they perceive themselves. I am trapped.

and gave up easily when a task proved to be difficult. Beck 1964). their goals and expectations. they may be altered by experience. Beck 1967). organisms need to be able to filter out the most relevant information if they are to survive and thrive. Cognitive theory posits that the processing of information is crucial for the survival of any organism. physiological. avoided making decisions for fear she would inevitably make mistakes with serious consequences. have lifelong patterns of dysfunction. and rules. which are under conscious control. Two kinds of schemas operate within the individual’s informationprocessing system. they may show dysfunctional patterns of behavior primarily during an acute episode. such as people’s perceptions of themselves and others. breadth. I won’t fail” and “If I rely on others. particularly by carefully designed learning experiences in therapy (Clark et al. memories. They have specific content in the form of beliefs. . and salience (A. and behavioral responses as mediated by their automatic thoughts. fantasies. 1999). Depressed patients show avoidance and isolation. Many dysfunctional behaviors of patients have consistent patterns. play a central role in one’s characteristic ways of interacting with the world. anxious patients are hypervigilant for threat (A. she avoided tasks she found challenging. To compensate for or cope with a very rigid. which are influenced by core beliefs. I’ll make terrible mistakes and have a bad life. developed over time some assumptions to guide her behavior and protect her from the activation of her core beliefs. core beliefs are stored in mental structures called schemas.T. Schemas vary in their density.” Thus. And they fail to develop a full repertoire of behaviors that are adaptive in many situations (J. accessible. in contrast. Beck et al. storing. 1990). goal-oriented activity. Perceptions of experience. and retrieving information. and previous learning (A. consist of personal goals and guiding principles of society. or compensatory strategies. Ms. If these patients have a good premorbid history. to get along in the world. According to cognitive theory.20 The Art and Science of Brief Psychotherapies incapable. like many patients with strong Axis II features. Because schemas are flexible to some degree. They are relatively flexible. rational thought. the cognitive model explains individuals’ emotional.T. Schemas are responsible for processing. I’ll be okay. permeability. my inadequacy will show” and “If I rely on myself. Constructive schemas. Given that the number of external stimuli in the environment is practically infinite. and elaborated and facilitate problem solving. global. A.” She also developed the opposite for each belief: “If I take on a challenge. Beck 1998). such as “If I avoid challenges. these patients often overdevelop a small set of behaviors.T. These guide productive. Axis II patients. negative self-view. assumptions.S.

Ms. or fight. Ms. A was not aware of her tendency to interpret information in this biased way. perhaps weak. for example. affective. themes of threat are hypervalent. they may run. their worlds. They feel sad. she discounted her successes: “Those things were easy to do. the individual tends to process information in a distorted way. When a primal schema is activated. Anyone could have done them. At the same time. Their systems become physiologically aroused to deal with perceived threat. behavioral. she understood the concept and was able to learn to correct her thinking. and evolutionarily linked to survival. motivational. Processing tends to occur at an automatic. They feel weighed down.”). or did not complete well enough.T. Even when they were called to her attention. they tend to dominate the information-processing system when they are activated (Clark et al. When Ms. on the other hand. heavy. Initially. They are dominated by ideas of loss or deprivation. Clusters of schemas activated together are called modes (A. dominance. empty. are rigid. sociability. escape. she saw evidence of what she believed was her fundamental inadequacy everywhere. level. Their motivation for productive activity decreases significantly. in her estimation. They feel anxious and fearful. or preconscious. 1999). Because they are associated with ensuring basic organismic needs (preservation. The cognitive underpinnings of psychopathology are rooted at a primal level at which information processing is dominated by primary modes. freeze. and guilty. Beck 1996). and physiological in nature. however. the individual tends to process positive information in a different way. Their behavior becomes markedly impaired as they isolate themselves and avoid (Clark et al. when primal schemas are activated. She blamed herself for not keeping her apartment in order. individuals see themselves. A began to focus on only the tasks at work that she did not complete. unelaborated. Primal schemas. She failed to recognize the tasks that she did well. and slow. discounting or ignoring it. A exaggerated the importance of her perceived weaknesses. It took me long enough. Schemas are cognitive. A was depressed. and if the threat is perceived as sufficiently severe. absolute. They are motivated to act in a way to reduce threat.Cognitive Therapy 21 and creativity. she instead construed her actions as a reflection of her incompetence. 1999). Once her therapist pointed it out. in contrast.” While Ms. Rather than understanding that her behavior reflected a psychiatric illness. and their future in a very negative light. . In a depressive mode. hopeless. she minimized her accomplishments (“So what if I finally got my taxes done. In an anxiety mode. She continually noted tasks at work that were more difficult for her. Patients view themselves or others as vulnerable to harm. She was self-critical of her procrastination in buying food and returning telephone calls. and reproduction).

A recent comprehensive review found considerable empirical support for the diathesis stress model of depression (Clark et al. She began to isolate socially and was thus deprived of social support. She experienced this as a severe blow to her self-esteem. The diathesis– stress model posits that not all negative events lead to depression. It allows the therapist to select key thoughts. Instead. During initial assessment. which teaches patients to view reality more clearly through an examination of their central. experienced several serious losses when her husband left her for another woman. beliefs. Principles of Cognitive Therapy The overall aim of cognitive therapy is to help patients achieve a remission of their disorder by solving problems and reducing symptoms. one who had provided financial. An accurate conceptualization helps the therapist to organize the multitude of data presented by the patient to identify the patient’s most central dysfunctional cognitions and behaviors. Correcting their faulty ideas leads to improvement in mood and functioning. She had lost her partner of 20 years. irresponsible. and behaviors to target for change. even in vulnerable individuals. The concepts de- . Her motivation to act productively declined. and her lack of energy in a negative light—as evidence that she was lazy. 1999). Ms. emotional. distorted cognitions. This is achieved through a collaborative. for example. to a lesser degree. She developed physiological signs of depression. and experienced a loss of energy. she began to have difficulty sleeping. Her depressive mode was fully activated. there was evidence to the contrary. She interpreted her lack of motivation. and inadequate. and practical support. the practice of cognitive therapy involves a cognitive formulation of patients’ disorders and an ongoing individualized cognitive conceptualization of patients and their difficulties. the depressive mode is activated when the type of negative stressor that has occurred matches the person’s underlying vulnerability. A summary of the basic principles of cognitive therapy is provided below. Soon she began to lose interest and pleasure in everyday activities and events.22 The Art and Science of Brief Psychotherapies How do modes become activated? Triggers of psychiatric symptoms involve individuals’ interpretations of their experiences. A. her changed behavior. as unlovable). and she developed a fullblown major depression. An individual with a schema of inferiority may become depressed following a demotion at work. She began to view herself as even more incapable than usual (and. even though from a rational viewpoint. empirical approach. felt weighed down. A person with a latent schema of unlovability may become depressed following the breakup of a relationship.

and problematic behaviors at the current time. Clinicians assume. S. frequency of visits. This teamwork is evident. that her expectations for herself were unreasonably perfectionistic. A’s therapist suggested to her that perhaps she had a belief that she had to please other people to gain their assistance. Clinicians start collecting data from their first contact with a patient. mutually deciding on problems to be discussed. she offered confirmation. J. homework assignments. emotional reactions. The third is particularly important in the treatment of personality disorders. offering specific data and an alternative view.Cognitive Therapy 23 scribed earlier concerning the general cognitive model are applied to patients’ idiosyncratic presenting problems. and so forth. The case of Ms. too. and reactions. A validly corrected him. When Ms. When they recognize consistent patterns in patients’ thoughts. until proven otherwise. behavioral. which not only strengthens the alliance but also allows the clinician to plan treatment more effectively. underlying assumptions. When her therapist made an incorrect hypothesis. that most patients are able to assess the validity of their clinicians’ hypotheses. clinicians start to fill in the cognitive conceptualization diagram. Ms. A is used as an example. Figure 2–2 depicts how therapists organize data derived from the patient to complete a cognitive conceptualization diagram. as clinician and patient engage in a process of collaborative empiricism to investigate the validity of the patient’s thoughts and beliefs. and physiological reactions. the bottom half of the diagram illustrates the basic cognitive model: in specific situations. The second involves the precipitating factors. a developmental framework is used to understand how early life events and experiences led to the development of core beliefs. The first is the patient’s thinking. the unique stressors or events that triggered the current episode. Cognitive therapy requires a strong therapeutic alliance. Cognitive therapy emphasizes providing rationales for interventions and eliciting and responding to patients’ feedback. and compensatory behaviors. question marks are used to note any hypothesis not yet checked out with the patient. The interpersonal factors—empathy. Clinicians do not know a priori whether any given . A’s early experience influenced her self-concept and led to the development of conditional assumptions and compensatory strategies. Beck (1995) described different time frames for this formulation process. and unconditional positive regard— that are important in any form of counseling are also essential in cognitive therapy. the patient’s automatic thoughts influence her emotional. The top half of the diagram shows how Ms. concern. Clinicians aim to create a collaborative relationship in which they function as a team with patients. beliefs.

MEANING OF AUTOMATIC THOUGHT I’m helpless. CORE BELIEF(S) I am helpless/inadequate. CONDITIONAL ASSUMPTIONS/BELIEFS/RULES Positive assumption(s): If I rely on others. EMOTION Sad MEANING OF AUTOMATIC THOUGHT I’m helpless. COMPENSATORY STRATEGIES Rely on others. Avoid challenges. Beck.S. AUTOMATIC THOUGHT How will I get along without him? AUTOMATIC THOUGHT I can’t do anything right. Negative assumption(s): If I have to rely on myself. AUTOMATIC THOUGHT I’m helpless.D. Defer to others’ wishes. Ph. SITUATION #3 Needs to take time off. She had a slight learning disability. Copyright J. I’ll be okay. 1993. sad MEANING OF AUTOMATIC THOUGHT I’m inadequate. was unreliable. did only “fair” at school. SITUATION #2 Sees unpaid bills. Parents expected patient to take on age-appropriate responsibilities. Source. Cognitive conceptualization diagram.24 The Art and Science of Brief Psychotherapies RELEVANT CHILDHOOD DATA Mother had mood swings.. I’ll fail. SITUATION #1 (Ex) husband announces he is leaving. EMOTION Anxious. EMOTION Sad BEHAVIOR Abuses alcohol BEHAVIOR Lies on couch BEHAVIOR Avoids asking Figure 2–2. .

They also develop cognitive and behavioral skills to use when they encounter stressors and note early warning signs of a recurrence. ultimately integrating them so that they become more automatic. then spaced out to every second. Cognitive therapy is educative in nature. Structure of the Therapeutic Interview The structure of the standard 45-minute interview generally follows a set format to maximize efficiency.g. A was able to see that her thought “I can’t do anything right” was patently false. or partly true and partly false. Treatment begins by discussing current problems of greatest distress to the patient. Because of its educative nature and its emphasis on acquisition of skills. Sessions are usually scheduled weekly (unless distress is severe).Cognitive Therapy 25 cognition a patient reports is wholly true. Research shows that cognitive therapy reduces the frequency and severity of relapse (Strunk and DeRubeis 2001). Patients’ core beliefs are modified (so that they are less vulnerable to an activation of negative schema under stress). or with chronic or treatment-resistant symptoms. with comorbid diagnoses. The chance of relapse is reduced in several ways. third. Axis I conditions such as anxiety disorders and unipolar depression usually respond to 6–12 sessions of cognitive therapy. and fourth week as patients use their skills independently and start to achieve a remission of symptoms. Together. Ms. She found that her thought “My boss won’t give me any time off” was also untrue when she tested it by asking him (after role-playing how to do so with her therapist). Longer courses of treatment (6 months to 1 year or more) are often required for patients with Axis II disorders. wholly false. Cognitive therapy is also goal oriented. cognitive therapy aims to be time limited.. During initial sessions. and therapeutic change. clinicians help patients specify their goals of treatment in behavioral terms (e. As with evaluating automatic thoughts. they test thoughts through an examination of the evidence or by setting up “experiments” for the patient to perform between sessions. learning. “How would you like to be different by the end of therapy? What would you like to see yourself doing?”). The therapist’s stated goal is to teach patients to become their own therapists. Key elements include • Mood evaluation and initial setting of the agenda • Bridge between sessions . Clinicians share their treatment plan and general strategies with patients so that patients can visualize more clearly how they will be able to reach their goals. By weighing the evidence. clinicians teach patients skills that they practice for homework.

between the previous session and the current one by asking patients what important events (positive and negative) have occurred.T. I’m glad to see that. Beck Anxiety Inventory (A. “In a few minutes. Beck et al. The mood evaluation often suggests important topics for the agenda (e. with both contributing important topics. the clinician and patient collaboratively prioritize the agenda. there is time to discuss only one or two problems in depth.”. Usually. Then therapists make a connection.T. self-administered symptom scales before each session.S. They also ask patients to recall the important skills they learned in the previous session and the important conclusions they reached. Maybe we should take a few minutes to talk about that later. the clinician does a combination of data collection. if that’s okay. They also review homework patients have completed during the week.. clinicians ask patients what problem(s) they want to put on the agenda. “It looks as if your sleep has deteriorated. discussing what they learned and deciding whether to continue the assignment in the coming week. and behavior. 1996). and Beck Hopelessness Scale (A. the clinician reviews patients’ total scores and individual symptoms. evaluating and responding to dysfunctional thoughts . and eliciting key cognitions.g. Concurrent with or subsequent to the mood evaluation. Beck and Beck 2001) are invaluable in providing the clinician with important data to guide the planning of the session and in helping the clinician and patient track progress. Can we put that on the agenda?”. I’d like to talk about why you think you’re feeling worse. in addition to requesting a verbal comparison of how patients have been feeling that week compared with other weeks. “So. Patients are usually asked to complete objective. presenting hypotheses. Beck and Steer 1989) or the Beck Youth Inventories (J. Beck and Steer 1990). T. Next. or bridge. conceptualization. you’re getting a lot more pleasure out of your activities.”). During the discussion of agenda topics. so they can build from one session to the next. they focus the session on alleviating their hopelessness and developing safety plans.26 • • • • • The Art and Science of Brief Psychotherapies Prioritization of the agenda Discussion of agenda topics and teaching of skills Homework Summary Feedback Each structural element is briefly described below. affects. During the mood evaluation. Scales such as the Beck Depression Inventory (A. If clinicians find that patients are suicidal. The clinician and patient then may perform a combination of problem solving.

Several minutes before their time is up. “What do I wish [this patient] would remember this week?” This question prompts the therapist to guide the patient in writing important points. the clinician continually thinks. Did I get that right?”). they do not wait until the end to ask for feedback. and behavioral skills training. Many Axis II patients benefit greatly from evaluating their cognitions about the therapist. what they have discussed: Therapist: Can you summarize what we just talked about? Patient: Well. the clinician can do the writing. Throughout the session. the clinician ensures that the most important points and the homework assignments are recorded in some way. . The purpose of another kind of capsule summary is to help clinicians assess the degree to which patients understand. You thought.’ These thoughts made you feel hopelessly sad. Rather. Throughout the session. Next time. I should use that hopeless feeling as a cue to figure out what I was thinking and remind myself that my thoughts may or may not be completely true. the clinician may summarize the patient’s narrative in the form of the cognitive model (“I want to make sure I’ve got it right. and you sat in the car and cried. The situation was that your car broke down. ‘This is the last straw. Or the two of them can make a 2-minute audiotape with the same information. clinicians or patients summarize the session. The clinician also elicits feedback: “What did you think of today’s session? Was there anything you thought I misunderstood or anything that bothered you? Anything you want to make sure we do differently next time?” If clinicians believe that patients are distressed during the session. If the patient prefers. and many include identifying and responding to distressing thoughts. correcting their thinking. Because most patients forget most of what was said during a given therapy session. coping skills. especially because I am depressed. I see how I let my thoughts run away with me again. I just bought into the idea that there was nothing I could do to fix the situation. and I gave up. responses to common automatic thoughts. doing experiments to test their thoughts. Homework assignments are a natural outgrowth of the discussion. and so on in a therapy notebook or on index cards. and tone of voice. and taking steps to solve problems. I can’t handle life anymore. and agree with. For example. practicing skills learned in sessions. facial expressions. the clinician makes capsule summaries.Cognitive Therapy 27 and beliefs. the clinician elicits the patient’s automatic thoughts right on the spot. noting the patient’s negative verbal and nonverbal responses. rehearsing new viewpoints. body language.

they . When these goals are achieved. while minimizing or failing to register positive events and data. including more than 75 outcome trials (Butler and Beck 2000). their personal world. patients are helped to change their depressed way of processing information and to engage in more functional behaviors. 1979). These patients overly attend to negative events and data. Anxiety The cognitive model of anxiety states that when individuals perceive significant risk and assess their ability to cope with the threat as low.28 The Art and Science of Brief Psychotherapies and learning to apply what they learned from the therapeutic relationship to specific relationships outside of therapy. and reducing his or her sense of hopelessness. The cognitions of depressed patients center on negative appraisals of themselves. termed the cognitive triad of depression (A. cognitive therapy was shown to be as efficacious as pharmacotherapy for even severe depression (Strunk and DeRubeis 2001). 1999). and a voluminous literature supports the efficacy of cognitive therapy for this disorder. In addition. and their future. rigid views at first and respond more positively to behavioral strategies. depressed patients who have been treated with cognitive therapy have half the relapse rate of patients treated with medication (DeRubeis et al. patients with severe depression often have difficulty modifying their extremely negative. The cognitive formulation of depression was introduced by A. This has the simultaneous effect of raising the patient’s energy level. Specific Applications Depression Cognitive therapy was initially developed for working with depressed patients. When patients are suicidal.T. Beck and colleagues in 1979. directly countering some of his or her distorted thinking. Although cognitive strategies are also used from the beginning. In a recent meta-analysis. clinicians explore the reasons behind their hopelessness and help them appraise their situations more realistically. providing a sense of pleasure and mastery. symptomatic reduction is usually complete.T. Initial treatment strategies usually include an emphasis on problem solving and behavioral activation. Beck et al. The content of their thoughts is pervasively pessimistic and negative. Behavioral activation also can provide the necessary energy and concentration to help the patient record and examine his or her thoughts. Overall.

with spreading branches of doom that become wider and wider (e. The critical cognitive distortion is related to catastrophizing. and to increase their internal and external resources to deal with the threat (A. Several anxiety disorders are described in this section. The cognitive hallmark of generalized anxiety disorder is that almost anything can be a source of worry.g. Features of anxiety disorders can be seen as excessive functioning of normal survival mechanisms. In addition. Therapy generally involves having patients learn skills to assess risk more realistically. Beck and Emery 1985).T. were reviewed by DeRubeis and Crits-Christoph (1998).. Generalized Anxiety Disorder The effect of cognitive therapy on generalized anxiety disorder has been addressed in several outcome studies.g. The automatic. to judge their resources more realistically. The same physiological reaction occurs in response to perceived threats from usually benign everyday stimuli (a crowd. the particular formulation and strategies vary somewhat from disorder to disorder.. whose control groups included a variety of conditions ranging from wait list to nondirective therapy to pill placebo. rapid branching of worries results in considerable exaggeration of the odds of negative outcomes—that is. an airplane. from minor details (e. an audience). deciding whether to take a new job or worrying about the illness of a family member). they find their anxiety difficult to control.. the patient is not likely to be evaluating all the different ways that things can turn out less drastically or even positively. have physical manifestations of fear. cognitive therapy was equivalent to nondirective therapy. The cognitions of the individual with generalized anxiety disorder represent a kind of worry tree. Patients with generalized anxiety disorder have patterns of negative predictions and excessive worry in several areas. and experience a reduction in functioning. In 10 of the 11 studies. an automobile repair. Because anxiety has several forms.g. “What if I don’t get home in time to greet my son after school? What if he can’t get in the house himself? What if no neighbors are home to let him in? What if he wanders in the street? What if he gets hit by a car?”). A total of 11 clinical trials. a missed dental appointment) to larger issues (e.Cognitive Therapy 29 feel anxious. and in one study. In addition to worrisome thoughts. patients often have scary images of the moment of catastrophe. cognitive therapy outperformed the control condition. Patients with generalized anxiety disorder . The evolution-based strategy for coping with threat is a physiological response that facilitates escape or self-defense. The individual sees problems as leading inevitably to disaster.

30 The Art and Science of Brief Psychotherapies also vastly underestimate their ability to cope with and handle problems that do come up. relaxation training can be very helpful in the early stages of treatment. Panic Disorder A review of 11 outcome studies examining cognitive therapy for panic disorder and panic disorder with agoraphobic avoidance concluded that cognitive therapy was an efficacious treatment for these disorders (DeRubeis and Crits-Christoph 1998). his or her health is in great jeopardy. maybe it won’t happen” or “If I’m alert to danger. learning new skills when necessary. behavioral strategies such as exposure exercises to anxiety-provoking situations can be useful to test the patient’s coping and worry-control skills.” Other assumptions are about the benefits of worry itself. panic patients are educated about the particular panic cycle in which they notice a bodily or mental change. such as “If I worry about something.” “If I make a mistake. then I’m in danger” or “If someone has an unexplained symptom. Thus. once the patient has the cognitive tools to defuse worry.” “This feeling of unreality in my head means I’m going crazy.” or “If I make a decision.” In treatment.” Patients with generalized anxiety disorder may benefit considerably from strategies designed to reduce physiological arousal. make a negative attribution. I’ll be able to protect myself. Therapy focuses on helping patients see alternative (benign) explanations for their catastrophic misinterpretations. Common misinterpretations include the following: “My rapid heartbeat and chest pain mean I’m having a heart attack. . Panic patients misinterpret a particular unexplained symptom or sensation (or a small set of related sensations) as a sign of an immediate mental or bodily catastrophe. they tend to perceive themselves as unable to implement the solution properly. Other beliefs involve a theme of vulnerability about themselves or others: “If the situation I’m in is not completely safe.” and “This feeling of dizziness means I’m going to pass out. Many patients with generalized anxiety disorder need to modify dysfunctional assumptions and beliefs. Thus. experience an intensification of their symptoms. This sense of inadequacy needs to be combated directly by having the patient engage in active problem solving. I’ll fail. Even if they do know what should be done. Some assumptions involve a negative assessment of their abilities and stem from a core belief of helplessness (“If I try to solve problems myself. feel anxious. patients are taught to assess risk more accurately and to enhance self-efficacy by expanding their resources. and practicing them. I’ll make the wrong one”). something terrible will happen. Also.

blood or injury) provokes both anticipatory anxiety and a physiological fear response.g. benign stimuli (such as a spider) are seen by the patient as having dangerous properties. patients’ predictions are recorded and evaluated to help them gain a more realistic sense of actual danger. As in panic disorder and agoraphobia. seeing the animal in a cage or another room. As in the treatment of panic disorder.g.. In some cases. therapy may begin with patients viewing pictures. they reinforce the idea that panic attacks are dangerous and must be averted. catastrophically misinterpret their symptoms. recording their thoughts. or taking benzodiazepines). finally. followed by closer and closer contact. clinicians perform panic inductions with patients (often by having them hyperventilate) to show patients that they brought on their symptoms and were then able to reduce them through their own behavior and change in thinking. all stores and malls). feelings. are not dangerous. a single panic attack in one location (e. Clinicians ask patients to monitor their safety behaviors. a bookstore) can lead to avoidance of an entire class of stimuli (e. it is critical to deal with anticipatory fears of being in a variety of situations. heights. Reviewers of this literature suggest that effective treatment includes exposure to feared stimuli. stopping an activity. imagining having contact with the animal. asking others for reassurance. enabling patients to disconfirm their cognitions about harm (Antony and Swinson 2000). although extremely uncomfortable. in which the least fear-provoking situations to those that are most fear provoking are listed.. a particular stimulus (e.. . leaving the situation. or actions to avoid or reduce symptoms (such as distracting themselves. and using anxiety management techniques they have learned in therapy. The aim of treatment is to have patients prove to themselves that their symptoms. Patients are encouraged to practice entering these situations on a daily basis. Specific Phobia For the specific phobias. For patients who also have agoraphobia. a fear hierarchy may be established. and sensations for discussion in session. an animal. Patients learn that the physical setting itself is not dangerous and gain confidence in their ability to manage their anxiety. Craske et al. Clinicians and patients construct a fear hierarchy.g. To do so. Throughout these exposures. Patients learn that their feared sensations can be produced in a variety of ways and do not lead to the feared consequence. A host of studies (e. an insect.g. As long as patients engage in these safety behaviors. 1995) have shown that cognitive-behavioral strategies are efficacious for the treatment of specific phobias.Cognitive Therapy 31 and. for example. closed spaces. For patients with animal phobias..

A meta-analysis of outcome studies also suggested that cognitive therapy (combined with exposure) was the approach that most consistently led to improvement (Taylor 1996). patients’ negative beliefs about themselves are modified. At the belief level. The clinician points out the self-defeating cycle of patients with social phobia (avoidance of socializing and engagement reinforces their negative beliefs about themselves and others. consume alcohol or other substances. In social phobia. Such behaviors are only short-term solutions. They engage in considerable mind reading and experience increased physiological arousal in response to actual or anticipated social interactions. of course. or socially defective in some manner. Exposure to anxiety-provoking social situations also may uncover safety behaviors that patients use to reduce their anxiety. patients with social phobia tend to see themselves as unlikable. they may assiduously avoid making eye contact with others. as in specific phobia or agoraphobia. In all of these studies. they may believe that they are constantly falling short of others’ expectations. making it more difficult to socialize and engage. Many patients with social phobia avoid or endure with dread a whole host of social situations. and demanding. stay rooted to a specific spot in a room (often a corner). . Patients are excessively preoccupied with thoughts that others do not like them or are evaluating them negatively. Cognitive therapy for social phobia combines both cognitive and behavioral strategies to reduce levels of anxiety and to combat concerns about negative evaluation. the critical cognitive factor usually involves a bias concerning what other people are thinking. As a result. These patients also may believe that others are harsh. For example. inferior. An initial goal is usually to construct a list of feared and avoided situations. and reinforce the notion that negative consequences would ensue if they were to behave differently. and so on) and encourages patients to practice new strategies learned in therapy. cognitive therapy outperformed the control condition.32 The Art and Science of Brief Psychotherapies Social Phobia Several studies have been carried out to examine the efficacy of cognitive therapy for social phobia. they assume that others are reacting to them negatively. or discuss only certain safe topics in conversation. Many of these patients also believe that their anxiety is visible to others and that any visible signs of anxiety will be interpreted as weakness if detected by others. some of which they may not reveal in a brief assessment. In addition. many patients with social phobia are poor at taking in external data. critical. patients then expose themselves to each of the situations in order of difficulty. Finally. at parties or social gatherings.

A. patients’ current degree of distress. 1990). clinicians consider many variables.. including obsessive-compulsive disorder (e. Cognitive Therapy Techniques In order to select which technique to pursue at any given point in a session. Fairburn et al. though. Every patient brings real-life problems to therapy.g. cognitive therapy also has been shown to be efficacious in a variety of other disorders. including the nature of the problem under discussion. and select a course of action. Ms. 1999). they need to help patients identify and respond to their distorted thinking before patients are ready to brainstorm options. At times.g.Cognitive Therapy 33 Other Conditions In addition to the examples presented here of cognitive therapy’s applications in depression and anxiety.. clinicians engage in straightforward problem solving with patients. posttraumatic stress disorder (Tarrier et al. for example. and marital problems (Baucom et al. Emmelkamp et al. 1983). Clinicians assess the degree to which they need to teach patients problem-solving skills directly. 1991). cognitive therapy has been found to be an effective adjunct to medication in patients with schizophrenia (A. Beck and Rector 2000). and how can I help the patient have a better week?” These questions also guide clinicians in planning strategy. help from a friend and a co-worker. eating disorders (e. Clinicians help patients break down seemingly insurmountable problems . and the strength of the therapeutic relationship. 1988). skills previously taught. Often. some of which are exacerbated by their faulty interpretations. patients’ and therapists’ goals. examine their choices. needed to evaluate her cognition “I shouldn’t inconvenience others” before she was ready to consider certain solutions. the stage of therapy.T. Clinicians continually ask themselves. such as asking for reasonable. Graded Task Assignments Graded task assignments are especially important for depressed patients. We discuss common techniques in this section. “How can I help this patient feel better by the end of the session. their overall plan for the session. and needed. Problem Solving Problem solving is a central part of cognitive therapy treatment. Most recently. substance abuse (Woody et al.

these patients invariably find that their mood improves when they push themselves to engage in formerly pleasurable activities and to perform tasks from which they can derive a sense of accomplishment. their mutual responsibilities as patient and therapist.34 The Art and Science of Brief Psychotherapies into component parts they can work on step-by-step. for 10–20 minutes at a time. A. they discovered that she was spending far too much time in the evenings and on weekends lying on the couch. This log can be invaluable in identifying activities that patients are engaging in too much or too little. They keep a log of what they are doing each hour and rate either their mood during each activity or their sense of pleasure or mastery. like Ms. Clinicians often encourage patients to read cognitively oriented pamphlets and chapters of self-help books to reinforce what they learned in therapy. Ms. the structure of the session. managing the household. how cognitive therapy proceeds. whichever seemed easiest. When Ms. and the cognitive model. the need for honest feedback. A found that she could actually continue working for much longer periods. the importance of setting agendas. She and her therapist discussed working on one room at a time. However. calling friends. are relatively inactive or whose lives are disorganized. Feeling much less overwhelmed by the task. A’s apartment was in general disarray. They recognized that she was not spending much time at all. Ms. including the symptoms of their disorder. A and her therapist examined her log. Activity Scheduling Behavioral activation and activity scheduling are particularly important for patients who. Activity Monitoring Activity monitoring is often used with depressed patients. . or gardening (her hobby). exercising. Depressed patients often believe that they should wait until they are feeling better before they attempt to engage in activities that can give them a sense of mastery or pleasure. watching television. and feeling very sad. reading magazines. if any. Such efforts are especially important when patients simultaneously experience interfering negative thoughts. Psychoeducation Psychoeducation is a key element in cognitive therapy. Clinicians educate their patients about many aspects of therapy.

they focus unduly on the negative and fail to register the positive things they are doing. for example.” . Getting out of bed. They tend to see their difficulties as being caused by an inherent character flaw instead of their illness. of course. learning to label these cognitive distortions also helps them gain some perspective on their thoughts. examining the utility of their thinking. clinicians use guided discovery. and paying a bill are all activities that merit credit.” She also made personalization errors: “Since my accountant was short with me. and planning a course of action. Because patients show characteristic errors in their thinking (Table 2–3). a gentle. he must be mad at me. To aid patients in evaluating their automatic thoughts and beliefs. Especially when patients are depressed.Cognitive Therapy 35 Giving Credit Many patients benefit from learning how to give themselves credit. getting distance from their thoughts through reflecting on advice they would give to others. Ms. Therapists not only help patients respond to their dysfunctional thinking but also teach patients how to do so. identify the distortions in their thinking. calling a friend. to modify patients’ dysfunctional cognitions. with how they were before they became depressed. The questions guide patients in evaluating the validity of their thoughts. Learning to compare themselves with how they were at their worst point reduces the hopelessness and self-blame they experience when they (automatically) compare themselves with others who are not depressed. Providing them with a list of questions (Table 2–2) allows patients to practice evaluating and responding to their thoughts between sessions. performing their usual hygiene activities. Socratic questioning process. decatastrophizing. Guided Discovery A major part of cognitive therapy is. seeking alternative explanations or perspectives. getting to work on time. Functional Comparisons of the Self Functional comparisons of the self are an important skill for many depressed patients. and I’m not. or with how they wish they would be. engaged in considerable all-or-nothing thinking: “Either I do everything well and I’m a good employee or I don’t. and develop more objective and adaptive viewpoints. A.” She often catastrophized or engaged in fortune-telling: “[My friend] won’t want to get together with me. if they were difficult for the patient to accomplish. One way to help them see the broader picture is for them to note (preferably in writing) whatever they do that is even a little difficult for them but that they do anyway.

Is there an alternative explanation? 3. What should I do now? Source. Cognitive distortions All-or-nothing thinking Also called black-and-white.36 The Art and Science of Brief Psychotherapies Table 2–2.” Also called fortune-telling. Example: “I’ll be so upset. You predict the future negatively without considering other. polarized.” You think something must be true because you “feel” (actually believe) it so strongly. Examples: “I’m a loser.S. I won’t be able to function at all. If [friend’s name] was in this situation and had this thought. Beck 1995. Example: “If I’m not a total success. Table 2–3.” You put a fixed. You view a situation in only two categories instead of on a continuum. or qualities do not count. global label on yourself or others without considering that the evidence might more reasonably lead to a less disastrous conclusion. what would I tell him or her? 6.” Catastrophizing Disqualifying or discounting the positive Emotional reasoning Labeling . What is the worst that could happen? How could I cope if it did? What is the best that could happen? What is the most realistic outcome? 4. but that doesn’t mean I’m competent. I’m a failure. deeds. more likely outcomes.” You unreasonably tell yourself that positive experiences. Adapted from J. Questioning automatic thoughts 1.” “He’s no good. I just got lucky. What is the evidence that supports this idea? What is the evidence against this idea? 2. or dichotomous thinking. but I still feel like I’m a failure. Example: “I did that project well. ignoring or discounting evidence to the contrary. What is the effect of my believing the automatic thought? What could be the effect of changing my thinking? 5.” Example: “I know I do a lot of things OK at work.

Example: “The repairman was curt to me because I did something wrong. Example: “Because I got one low rating on my evaluation [which also contained several high ratings]. Dysfunctional Thought Record A tool that is useful for most patients (although sometimes in a simplified form) is the dysfunctional thought record (Table 2–4). He’s critical and insensitive and lousy at teaching. Cognitive distortions (continued) Magnification/ minimization When you evaluate yourself.Cognitive Therapy 37 Table 2–3. 1995.” Mental filter Mind reading Overgeneralization Personalization “Should” and “must” statements Tunnel vision Source.” Also called selective abstraction.” You make a sweeping negative conclusion that goes far beyond the current situation.” You believe others are behaving negatively because of you. Getting high marks doesn’t mean I’m smart. I don’t have what it takes to make friends. Example: “It’s terrible that I made a mistake. Used with permission. more likely possibilities. another person. it means I’m doing a lousy job. Example: “He’s thinking that I don’t know the first thing about this project. Guilford. you unreasonably magnify the negative and/ or minimize the positive. Many patients use this worksheet not only during therapy but also . I should always do my best. Example: “Because I felt uncomfortable at the meeting. Example: “Getting a mediocre evaluation proves how inadequate I am. or a situation. failing to consider other.” You believe you know what others are thinking. This worksheet allows patients to record and respond to their thoughts in an organized way. New York. You have a precise.” You only see the negative aspects of a situation. fixed idea of how you or others should behave. You pay undue attention to one negative detail instead of seeing the whole picture. and you overestimate how bad it is that these expectations are not met. Example: “My son’s teacher can’t do anything right. Reprinted from Beck JS: Cognitive Therapy: Basics and Beyond. without considering more plausible explanations for their behavior.” Also called imperatives.

Patients are told that the efforts are worthwhile if they achieve even a 10% reduction in their distress. Correctly identifying and differentiating among the initial elements (situation. Predictions such as “I won’t get any enjoyment from having lunch with my friend.” “If I try to sort out my medical records. For example. emotion) requires practice. The questions listed in Table 2–2 are printed at the bottom of the record so that patients can refer to them in formulating an adaptive response (which they write in the next column). and may help the patient compose a useful response to read in case the experiment does not go well. evaluating the patient’s conclusion. Finally. They also re-rate their degree of emotion in the outcome column. and reading her therapy notes at work when she was dis- . I’ll make serious mistakes. A’s thought “I can’t concentrate well enough to do my work” appeared to be substantially true.38 The Art and Science of Brief Psychotherapies for months and years after therapy is over. taking brief walks outside during her work breaks. automatic thoughts. Behavioral Experiments Behavioral experiments help patients test their automatic thoughts that are in the form of predictions. Ms. to increase the odds of success. the first three columns after the date parallel the cognitive model: patients record their thoughts and emotions in specific situations.” “My mother won’t listen to me at all if I try to explain why I can’t come home next week. The clinician helps set up the experiment carefully. although frequently they gain much more relief if they have been able to complete the worksheet appropriately. clinicians usually do one or more of the following: problem solving. On the dysfunctional thought record. patients re-rate how much they still believe their automatic thought. When patients’ thoughts are valid. A and the clinician talked about improving her sleep.” and “My friend will get mad if I suggest that we do something else” can be empirically tested. Clinicians do not ask patients to complete dysfunctional thought records at home until patients show facility with these tools in session. when they find that they are overreacting to situations or developing early warning signs of their disorder. Responding to Patients’ Valid Thoughts Sometimes patients’ thoughts are valid. to determine whether further intervention with the distressing thought is needed. or examining the utility of the thought. Patients are also instructed to note their degree of belief in each thought and the intensity of their emotion. Ms.

the emotion? one at the time? distressing physical 3. Date/ time Automatic thought(s) Emotion(s) Alternative response Outcome Situation 1. angry) did you feel went through your or daydreams. and/or image(s) stream of thoughts. (optional) What cognitive 1. 39 . catastrophizing) 2. Sad (70%) 2. automatic thought? (e. How intense unpleasant emotion? 2.. What will you do 3. I’m struggling with depression and still functioning even if I’m not doing as well as when I’m not depressed. anxious. 2. What actual event or 1. What emotion(s) 1.. jot down the thought or mental image in the “Automatic thought(s)” column. What thoughts now believe each distortion did you make? (e. (100%) Sad (85%) Labeling error 1. all-or-nothing thinking. My house is messy. or mind reading.g. sad. How much did intense (0%–100%) compose a response to the (0%–100%) was you believe each 2. 70% at work. Dysfunctional thought record Directions: When you notice your mood getting worse. What emotion(s) do at the time? mind? recollection led to the you feel now? How 2. How much do you 1. What (if any) is the emotion? automatic thought(s). ask yourself. “What’s going through my mind right now?” and as soon as possible. I cry all the time. Use questions at bottom to 2.Cognitive Therapy Table 2–4. I’m behind 1. How much do you believe sensations did you (or did you do)? each response? have? 6/15 Seeing how messy the apartment is I’m a total basket case. But I am still going to work every day and getting some things done.g.

80% Note. what would I tell him or her? 6) What should I do now? Source. Copyright J. . Beck. G that she has an illness caused by depression and that doing something about the messiness will make her feel better. 1993.Table 2–4. 4. I would tell Ms. Most realistic outcome: Maybe this therapy will continue to help. 40 The Art and Science of Brief Psychotherapies 5. If I change my thinking. Thinking this way makes me feel worse. Ph. Best outcome: I’ll start feeling great today. 5.. I cleaned the kitchen. Worst outcome: I’ll stay depressed. 6. Dysfunctional thought record (continued) Date/ time Situation Automatic thought(s) Emotion(s) Alternative response 3. Questions to help compose an alternative response: 1) What is the evidence that the automatic thought is true? Not true? 2) Is there an alternative explanation? 3) What is the worst that could happen? Could I live through it? What is the best that could happen? What is the most realistic outcome? 4) What is the effect of my believing the automatic thought? What could be the effect of changing my thinking? 5) If [friend’s name] were in this situation and had this thought.S. I should start cleaning the kitchen for 10 minutes. Outcome 3.D. I’ll function better.

at lunchtime. Eventually. Ms. Imagery Work Imagery work is quite important for many patients. Weighing Advantages and Disadvantages Another common technique when patients must make decisions is helping them identify. following an image through to completion.” Her therapist used several of the cognitive techniques discussed earlier to help Ms.” Evaluating and responding to this conclusion reduced Ms. A’s clinician taught her some imaginal techniques to reduce her distress: checking the reality of an image. Ms. Usually they contain responses to patients’ key. A also benefited from a card designed to get her up and going on weekends. and at break time. Ms. and whether it would be worthwhile to take social risks to enlarge her network of friends. Ms. recurrent automatic thoughts or behavioral instructions. A to record her response on a card to read on her way to work. A modify her thinking and then asked Ms. A needed a robust response to her distressing automatic thought “If I don’t do well at work. whether to take medication. again. As Table 2–4 illustrates. especially those who experience automatic thoughts in an imaginal form. She and her therapist also examined the usefulness of the thought. In addition to verbal automatic thoughts. this card was collaboratively composed. images of an acquaintance rejecting her. record. it means I’m a failure. A’s therapist used this technique to help her decide whether to talk to her boss about her depression. I can’t concentrate. and memories of difficult times in a previous job.Cognitive Therapy 41 tracted by her usual automatic thoughts. Ms.” Coping Cards Coping cards (Figure 2–3) are really just therapy notes on index cards that patients can carry with them and read several times a day. She and her therapist also discussed advantages and disadvantages of her belief “I should avoid conflict at any cost.” just served to prolong her distress. Ms. . and perhaps weigh advantages and disadvantages. A was able to see that continually saying to herself. and changing a key element of the image. A had images of her boss yelling at her. “I can’t concentrate. Ms. it means I am an utter failure. A’s distress. A had also reached a distorted conclusion from her valid thought “Since I can’t concentrate well enough on my work.

g.42 The Art and Science of Brief Psychotherapies Automatic thought: I’m a failure. other patients with anxiety are encouraged to eliminate their use of safety behaviors (e. Relaxation Training Many patients. Response Prevention Response prevention is used with obsessive-compulsive disorder patients to decrease their compulsive behavior.. Graded Exposure Graded exposure is often used with anxious patients. increase their anxiety tolerance. getting some things done.g. Rigid. Response: I’m having problems because I’m depressed. imaginal exposure. Sample coping card. Figure 2–3. long-standing beliefs usually require a variety of interventions over time. avoiding situations. That’s not me.. a full description of which is beyond the scope of . and doing essentials such as going to the store and doing laundry. who create a fear hierarchy and gradually expose themselves to feared situations. especially patients with anxiety. Likewise. and test their predictions. muscle relaxation. Modification of Underlying Beliefs Modification of underlying beliefs entails many of the techniques listed in this section. using cognitive and behavioral skills they learned in therapy to decrease their anxiety and obtain a sense of mastery. trying to keep their emotions in check) that perpetuate their dysfunctional beliefs. A real failure is someone who is not depressed but still makes no effort at all to do anything. I’m still going to work every day. meditation) or controlled breathing (especially those who tend to hyperventilate) useful. find relaxation training (e. And even though I’m depressed.

• Supportive techniques include empathy. Beck et al. and learning to focus externally instead of on internal sensations. Clinicians also help patients tolerate negative affect and modify dysfunctional beliefs about emotions: “If I start to feel distressed. assertiveness. elicit their automatic thoughts about the therapist and therapy. identifying alternative explanations for patients’ experiences when the belief has been activated. • Transference techniques framed in a cognitive manner may be needed for Axis II disorders. developing more realistic.Cognitive Therapy 43 this chapter. monitoring the operation of the schema.T. • Experiential techniques include role-playing. reduction of caffeine or other drugs. 1990 and J. and providing positive reinforcement. Some techniques include examining advantages and disadvantages of holding a particular belief. • Environmental interventions might include helping patients make changes in living or work environments. and examining the developmental origin of beliefs (see A. showing an accurate understanding of the patient’s experience. I’ll get completely overwhelmed and will not be able to cope with it. using metaphors and analogies to help patients develop new perspectives. using rational–emotional role-plays. learning to recognize evidence that disconfirms the dysfunctional belief. Beck 1995 for a thorough presentation of these interventions). selfsoothing activities. and help them evaluate and respond to their cognitions and generalize what they have learned to other relationships. and reading therapy notes. and modifying beliefs through imaginal reexperiencing of previous trauma. exercise. controlled breathing. solving interpersonal problems. inducing positive imagery. Other Techniques Many other techniques have cognitive and behavioral aspects but may be classified differently: • Emotional techniques may include teaching patients to regulate affect through behavioral activities: distraction. • Biological interventions might include use of medication (if indicated). more functional beliefs.S. and other social skills.” • Interpersonal techniques include correcting faulty beliefs about others. responding to distressing imagery in imaginal form. as clinicians note patients’ verbal and nonverbal signs of distress. explaining faulty information processing. seeking support. . and learning communication. Clinician and patient may collaboratively decide to bring significant others into one or more sessions. creating cognitive continua.

she drank heavily and continued to do so for many years until she completed an inpatient substance abuse program 6 years ago. had occurred nearly 20 years before. Initially. A was a 52-year-old divorced woman with three grown children living in other cities. graded task assignments to guide her in straightening up her apartment. In the following example. when her first husband announced that he was in love with another woman. Feelings of rejection were bad enough. and she became willing to reach out to friends. Ms. emotional support. A and the therapist initially agreed to work on the thought “I’m a complete idiot [because I can’t even turn the computer on]. such as paying bills and making major and minor decisions. and she also showed strong dependent features on Axis II. A started functioning much better. and day-to-day activities of living. dealing with urges to drink. Always. Ms. Through activity scheduling. Not knowing which of several switches was the right one. the therapist helps her focus on positive data that she has not been taking into consideration. A Ms. Her mood improved. so you couldn’t find the “on” button. A reported that she had felt terrible earlier that day. the therapist loosely follows the list of questions in Table 2–2. they discussed the validity of the thought: Therapist: Okay. She was given a diagnosis of major depression. Although it had been a casual relationship that had ended by mutual agreement. A’s current episode of depression was triggered 5 months ago when a relationship with a boyfriend ended. A and her therapist focused on several problems: responding to her mild suicidal thoughts. During the first part of treatment. Her most severe episode of depression. and getting her behaviorally activated. but Ms. A had a series of thoughts that led her to feel sad (80%) and anxious (60%). . She had withdrawn from friends and spent most of her nonwork hours watching television. Early in treatment. moderate (score of 33 on the Beck Depression Inventory II at intake).” which she believed 100%. and posing assignments as experiments to test her thoughts that she could not do things. A notes a few other things. I will be lost. Ms. A: I always have trouble with machines. she feared a potential relapse. she began to have thoughts such as “I’ll never find anyone else” and “If I am alone. A’s therapist taught her cognitive skills as well. She had been in a computer class mandated by her workplace. These included identifying her automatic thoughts when she was distressed or noticed herself avoiding situations and then evaluating and responding to them. reading coping cards reminding her of the advantages of being active. Ms. recurrent. which lasted for more than a year. Ms. Any other evidence that you’re an idiot? Ms. During the subsequent separation and divorce.” Although she had not taken a drink. Ms.44 The Art and Science of Brief Psychotherapies Summary Case Illustration: Ms. She had worked full-time as a nurse’s aide in a community clinic for the past 10 years. Ms. After Ms. A was even more despondent over her loss of a partner for financial security. The specific situation was that the instructor had told the class to switch on their computers.

but not with computers. Therapist: Yeah. when you say it now. Therapist: Let me ask you this. A: Not necessarily. Next. it sounds extreme to me. A: There were lots of buttons and stuff. A’s thought that she is an idiot. [providing psychoeducation] This is an example of what happens when we are depressed and anxious. are you saying that at worst. . you’re an idiot with computers and maybe other machines but not a complete idiot? Ms. then see if they learned once they had been shown. you wouldn’t expect so if they had not seen one before. I’d call that more than unfair. [providing an analogy] Let’s imagine I take someone who has had no experience with cars at all. the therapist helps her recognize an alternative explanation for her difficulty. Therapist: That seems more fair to me. I’ve avoided them totally. Therapist: [collecting data] Have you ever worked on a computer before? Ms. You’d have to teach the person first. Therapist: Absolutely. they probably would be a little lost. A: No. A: You know. A: I suppose it does. Is that a reflection on their intelligence? Ms. and so what does that say about whether you’re really “an idiot”? Ms. the therapist decatastrophizes the situation. 45 After eliciting more data that contradict Ms. A: I guess so. we tend to zero in on negative information about ourselves and don’t really consider all of the facts before we reach a conclusion. Therapist: [pauses] Can you think of any other explanation for why you didn’t know where the right switch was? Was there more than one switch? Was it marked? Ms. Therapist: I think you’re right. Does that tell you anything about your computer class experience? Ms. Therapist: So. I guess there’s no way I would know which button to push. has never even been in a car. A: Well. A: Well. Not until the instructor had to come over and show me. and I put that person in my car and I say.” Would they know what to do? Ms. I didn’t know what any of them meant. maybe. “Start it up. A: I don’t know.Cognitive Therapy Therapist: Any evidence on the other side? That maybe you’re not an idiot? Ms. I’ve been afraid of them. Therapist: How about the fact that you recently got a bonus at work? Doesn’t that indicate that your boss feels you’re doing a good job? Ms.

A. A: No. Therapist: So. A: Wow. the instructor wasn’t that good—if he was going too fast for other people. what’s the best thing that could happen in this situation? Ms. the therapist has Ms. A: Yeah.46 The Art and Science of Brief Psychotherapies Therapist: Ms. A: Maybe. they discuss the effect of Ms. After Ms. Therapist: Ms. Therapist: Could you talk to other people or to him? Ms. I don’t remember most of it. Then the therapist asks Ms. probably. A what she would tell her friend Ms. too. A to summarize her new conclusion and her homework—to talk to the instructor. A had begun functioning better and had learned the tools to respond to her distorted thinking. what’s the worst that could happen if you don’t learn the computer? Ms. what would you do? Ms. [pauses. Finally. what did you do last time? Ms. I think so. maybe rather than your being an idiot. That I’d keep my job. Therapist: What do you think is the most likely outcome? Did you learn something from that first class? Will you have more classes? Ms. A: The instructor went over a lot of things. A: I suppose so. To counter this belief. A: Yeah. G if Ms. it’s been a while since I looked for a job. Therapist: If worse came to worst. her therapist started to focus on her belief about inadequacy. A re-rate how much she still believes she is “a complete idiot” and the degree to which she is still sad and anxious about it. A’s telling herself that she is an idiot and the benefits of seeing this situation from the new perspective. A . the therapist asks Ms. Therapist: Well. A: Yeah. A: I guess I’d be fired. would the most likely outcome be that it might take time and a lot of practice but that you would catch on? Ms. A: I looked in the newspaper. G were ever in this situation. I do know how to type. Therapist: If you did get fired. Noting significant change. then does problem solving] Do you think if you and the others went to him and asked him to slow down that you’d be more likely to catch on? Ms. A. Therapist: Or might they move you to some job that didn’t require computers? Ms. Therapist: Assuming you do so. her therapist had Ms. Next. Therapist: Were other people doing everything easily? Ms. would you do that again? Would you find another job? Ms. A: I guess I’d be able to learn to do the computer. It’s the other stuff I don’t know. everyone was complaining afterward.

The therapy is based on a largely empirically supported theory. She also learned to see improvements in her mood and functioning as the result of her own efforts. Toward the end of therapy. Ms. including (as an adjunct to medication) bipolar disorder and schizophrenia. A collected her therapy notes. References Antony MM. Sayers S. noted the tools that had helped her the most. Swinson RP: Phobic Disorders and Panic in Adults: A Guide to Assessment and Treatment. learning to use the techniques on herself. DC. getting her taxes finished on time. intervals. and devised a system for reviewing what she had learned. her depression was in full remission. They discussed potential problems that could arise in the next year and engaged in advanced problem solving. Ms. J Consult Clin Psychol 58:636–645. She and her therapist discussed her early warning signs of depression. Ms. in fact. and suggesting social activities to friends. it has now been extended to and tested for a range of psychiatric disorders. “If I had had you there. At the end of that time. Washington. Early on. A and her therapist concentrated on relapse prevention. counter to her predictions: being assertive with her boss. Developed as a treatment for unipolar depression in adults. Ms. and Ms. and for many medical problems as well. A had shown a tendency to rely on her therapist. 1990 . Ms. Ms. Treatment proceeds from a cognitive formulation of the disorder and a cognitive conceptualization of the individual patient and emphasizes the modification of distorted and dysfunctional cognitions to bring about enduring cognitive. A was able to use the skills she had learned to respond to them and decrease her anxiety. and behavioral change. and then 4-week. with the final 4 sessions spaced at 2-week. A was seen for a total of 13 sessions.” The therapist pointed out that there was nothing special about the questions and techniques used by the therapist and that she was. A’s therapist also elicited her automatic thoughts about ending therapy. I know you could have helped me feel better. American Psychological Association. emotional.Cognitive Therapy 47 keep logs of experiences in which she functioned adequately or better. 2000 Baucom D. and she wrote down a plan of action should they recur. Sher T: Supplementary behavioral marital therapy with cognitive restructuring and emotional expressiveness training: an outcome investigation. Conclusion Cognitive therapy has been shown to be an efficacious and efficient form of treatment for a wide range of psychiatric disorders. A surprised herself by doing several behavioral experiments that turned out well. saying.

Harper & Row. 6th Edition. 2000 Clark DA. San Antonio. Arch Gen Psychiatry 9:324–333. Crits-Christoph P: Empirically supported individual and group psychological treatments for adult mental disorders. New York. Steer RA: Beck Anxiety Inventory Manual. Rector NA: Cognitive therapy of schizophrenia: a new therapy for the new millennium. 1997. Peacock. in American Psychiatric Press Review of Psychiatry. Shaw BF. personality. 2000. New York. Brown GK: Beck Depression Inventory—Second Edition Manual. 1995 Beck JS: Cognitive approaches to personality disorders. Behav Res Ther 33:197–203. Itasca. 1990 Beck AT. Bull Menninger Clin 62:170-194. TX. Basic Books. Washington. San Antonio. Steer RA: Manual for the Beck Hopelessness Scale. 2001 Butler AC.48 The Art and Science of Brief Psychotherapies Beck AT: Thinking and depression: idiosyncratic content and cognitive distortions. Freeman A. Beck JS: Cognitive therapy outcomes: a review of meta-analyses. J Consult Clin Psychol 66:37–52. TX. Emery G: Anxiety Disorders and Phobias: A Cognitive Perspective. Psychological Corporation. 1990 Beck AT. New York. in Frontiers of Cognitive Therapy. Beck AT: Beck Youth Inventories Manual. pp I-73–I-106 Beck JS: Complex cognitive therapy treatment for personality disorder patients. et al: Cognitive Therapy of Depression. Experimental. New York. and Associates: Cognitive Therapy of Personality Disorders. Oldham JM. TX. Arch Gen Psychiatry 10:561–571. Guilford. DC. Riba MB. 1963 Beck AT: Thinking and depression: theory and therapy. Rush AJ. Psychological Corporation. New York. pp 241– 272 Beck AT. Psychological Corporation. Wiley. Wedding D. 1985 Beck AT. Beck AT. Guilford. San Antonio. Alford B: Scientific Foundations of Cognitive Theory and Therapy of Depression. 1967 Beck AT: Beyond belief: a theory of modes. Weishaar ME: Cognitive therapy. Edited by Salkovskis P. pp 1–25 Beck AT. Steer RA. New York. 1964 Beck AT: Depression: Clinical. 1998 Beck JS. 1996 Beck JS: Cognitive Therapy: Basics and Beyond. Vol 16. Guilford. et al: Treatment of claustrophobias and snake/spider phobias: fear of arousal and fear of context. Tidsskrift for Norsk Psykologforening [Journal of the Norwegian Psychological Association] 37:1–9. Edited by Corsini RJ. 1989 Beck AT. and psychopathology. Guilford. Am J Psychother 54:291–300. 1996. 1998 . San Antonio. TX. 1979 Beck AT. 2000 Beck AT. 1995 DeRubeis RJ. Edited by Dickstein L. Yi J. Mohlman J. American Psychiatric Press. 1999 Craske MG. Psychological Corporation. and Theoretical Aspects. New York. IL. in Current Psychotherapies.

American Psychological Association. 1991 Strunk DR. 1988 Fairburn CC. 2001 Tarrier N. Pilgrim H. et al: Three psychological treatments for bulimia nervosa: a comparative trial. Luborsky L. DC. et al: A randomized trial of cognitive therapy and imaginal exposure in the treatment of chronic posttraumatic stress disorder. Arch Gen Psychiatry 48:463–469.Cognitive Therapy 49 DeRubeis RJ. Does it help? Arch Gen Psychiatry 40:639–645. Gelfand LA. DeRubeis RJ: Cognitive therapy for depression: a review of its efficacy. Peveler RC. 1999 Emmelkamp PMG. Freeman AS (eds): Cognitive-Behavioral Group Therapy for Specific Problems and Populations. Cognitive Therapy and Research 12:103–114. 1996 White JR. Visser S. Hoekstra RJ: Cognitive therapy vs exposure in vivo in the treatment of obsessive-compulsives. 2000 Woody GE. et al: Medications versus cognitive behavior therapy for severely depressed outpatients: mega-analysis of four randomized comparisons. 1983 . Sommerfield C. Tang TZ. Washington. 1999 Taylor S: Meta-analysis of cognitive behavioral treatment for social phobia. J Consult Clin Psychol 67:13–18. Journal of Cognitive Psychotherapy: An International Quarterly 15:289–297. McLellan AT. Jones R. et al: Psychotherapy for opiate addicts. Am J Psychiatry 156:1007–1013. J Behav Ther Exp Psychiatry 27:1–9.

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because thorough assessment is a crucial first step in behavioral interventions. we briefly review some of the evaluation techniques commonly used by behavior therapists. Bux Jr. particularly for their efficacy in the treatment of pathological anxiety: a commonly used form of anxiety management training called stress inoculation train51 I . We begin with a general description of the behavioral approach to psychotherapy. Hembree.D. Edna B.. the behavioral treatments described in this chapter are among those that have amassed strong empirical support. we describe an approach to psychotherapy that has produced a vast body of literature in recent years. n this chapter.3 Brief Behavior Therapy Elizabeth A. Ph. numerous treatment outcome studies have generated considerable knowledge about the efficacy of behavioral interventions. We describe two types of behavior therapy that have received much empirical support.D. Ph. Next.D. Donald A. Ph. In particular. Deborah Roth. Ph. Although a review of the treatment efficacy literature is beyond the scope of this chapter. Foa.D.

This likely plays a role in the good long-term efficacy of behavior therapy across a range of disorders (see Mavissakalian and Prien 1996). the chapter contains many other clinical examples of the interventions we describe. our presentation of the application of behavior therapy to psychological problems focuses primarily on the treatment of anxiety disorders. This spirit of empiricism has a strong influence on the tone that is set in behavior therapy. The second reason is that the large body of literature in the anxiety disorders domain supported our aim of presenting theoretically and empirically grounded brief therapeutic interventions. we present detailed descriptions of two exposure-based treatment programs that have been developed and extensively studied at the Center for the Treatment and Study of Anxiety (CTSA) at the University of Pennsylvania in Philadelphia. our aim as therapists is for patients to become experts in their own treatment. Second. As is suggested by the preceding overview. Therapeutic techniques are directly related to the way in which disorder etiology and maintenance are conceptualized. Although behavior therapy is commonly used for a wide variety of other disorders and problems in individuals of all ages (e.g.. After introducing these techniques. These are the Exposure and Ritual Prevention (EX/ RP) program for the treatment of obsessive-compulsive disorder (OCD) and the Prolonged Exposure (PE) Therapy program for the treatment of chronic posttraumatic stress disorder (PTSD). The first is that our expertise and our clinical experience lie primarily in the study and treatment of disorders in this diagnostic category. . First. they will be able to continue applying what they have learned long after treatment has ended. Patients are educated about the behavioral approach to understanding and treating their particular problems. Psychoeducation is a major component of behavior therapy treatment programs. personality disorders).52 The Art and Science of Brief Psychotherapies ing (SIT) and exposure therapy. impulse-control disorders. patients will be more likely to comply with therapy if they understand why they are being asked to do particular exercises. In doing so. Each type of treatment is illustrated by a detailed case example. child behavior disorders. we restrict our focus to adult anxiety disorders for two reasons. General Description of Behavior Therapy Behavior therapy is notable for its empirical approach to developing intervention techniques and evaluating their efficacy in the treatment of a range of psychological problems. marital and family problems. mood disorders. The goal of psychoeducation is twofold. In addition.

Some time is spent during psychoeducation speaking very generally of why people might develop a particular disorder. homework practice increases the likelihood that patients will habituate to or experience a decrease in the anxiety that arises in feared but “safe” situations. It begins with 2 sessions of psychoeducation and information gathering and progresses to 15 sessions of EX/RP. is followed by in vivo and/or imaginal exposures. and psychoeducation have been accomplished. Traditional psychodynamic therapy is typically long term. Practicing skills between sessions increases patients’ proficiency with them and also promotes a sense of mastery and confidence. the treatment program for OCD used at the CTSA consists of 17 sessions. problem solving. but this conversation is general to the disorder more than it is specific to the patient. including exposure. treatment planning.Brief Behavior Therapy 53 The duration of behavioral treatment often differs from that of more traditional forms of psychotherapy. with no set end point. Behavior therapy patients often find the present-centered or here-and-now focus of attention to be quite refreshing. Each EX/RP session begins with a review of homework. behavior therapy is a very active treatment. clinicians usually have a good estimate of how many sessions will be required. For the exposure-based treatments (described later in this chapter). At the initiation of behavior therapy for a specific problem. Once assessment. an integral component of behavior therapy is homework. It also provides patients with more opportunities to . most sessions of behavior therapy involve participation in active behavioral techniques. Many of our patients with anxiety disorders know that insight is often helpful. For this reason. and role-playing. With this focus on making changes in current behavior. This active approach carries over to the time between sessions. Focus is usually placed on one problem. Some specific phobias can be treated effectively in a matter of hours. behavior therapy focuses on making changes in current behavior and on how to maintain these changes in the future. Another unique aspect of behavior therapy is that little attention is dedicated to figuring out the origins of the patient’s problem. but figuring out why they have a particular problem does not necessarily change their current situation. relaxation. As is outlined later in this chapter. and a great majority of the treatment time involves dealing with that problem. There is very little unfocused talking and a lot more active doing. and is closed with assignment of homework. even severe cases of other anxiety disorders can be treated in fewer than 20 sessions. Significant gains are often made quite quickly in behavior therapy because it is problem focused and present focused. Clinicians initiate a course of behavior therapy knowing not only how the treatment as a whole will progress but also what each treatment session should entail.

.e. I managed just fine”). The therapist has expertise and experience that may help the patient with his or her problems. The relationship between behavior therapist and patient is highly collaborative. and although I felt the symptoms of panic. the therapist usually describes the conceptual model underlying the treatment as clearly as possible. and homework assignments is collaborative.. When the therapist provides education in the early sessions of therapy about the patient’s disorder and recommendations for treating it. Given these positive aspects of homework. Another critically important component of behavior therapy is the presentation of a clear and credible treatment rationale. the therapist communicates his or her understanding of the patient’s unique situation by including specific examples from his or her particular experience and symptoms. The reasons that the therapist thinks particular skills or specific therapy procedures will help the patient’s problems are made clear. “I rode the subway every day this week. As in most forms of psychotherapy. decision making about the frequency of sessions. Homework also provides important opportunities for patients to learn that they can use their newly acquired skills to manage alone (i. To accomplish this. The use of metaphors or analogies can be helpful in presenting a convincing rationale by illustrating the treatment model and giving the patient and the therapist something to refer to as therapy progresses. De Araujo et al. a strong therapeutic alliance is critical.g. but the therapist seeks the patient’s full and knowledgeable participation in treatment planning and decision making. without the therapist) and in real-life settings outside the therapist’s office. The patient must “be on board” or accept the rationale in order to follow the therapy plan both in and out of session.g. target problems.. with the goal of helping the patient see that it makes sense and “fits” with the patient’s experience. with the therapist making recommendations but taking into consideration the patient’s preferences and judgment. 1996. For example. Doing homework also gives them an opportunity to “be their own therapist. The therapist begins to establish this alliance at the very first meeting by acknowledging the patient’s courage in entering treatment and supporting his or her desire to learn new ways to cope with problems.” a role in which we would like patients to feel comfortable at the end of treatment.54 The Art and Science of Brief Psychotherapies have corrective learning experiences within their feared situations (e. As treatment progresses. in PE therapy for treatment of PTSD. we sometimes liken the process of confronting and describing painful trauma memories to the . Leung and Heimberg 1996). it comes as no surprise that homework compliance is a good predictor of treatment outcome (e.

.g. quality of life.Brief Behavior Therapy 55 cleaning of a wound that has scabbed over but is not healed and remains sensitive to touch. present-centered.. problem-focused. The process of assessment and diagnosis is best accomplished with a clinical interview. suggesting the presence of a specific phobia of flying. behavior therapy is empirically based.g. Self-report measures (e. Or the patient might fear having a panic . The patient might fear being in an airplane crash. collaborative. A diagnosis rarely can be made solely on the basis of the patient’s simple description of a presenting problem. difficulties with anger). consider a patient who presents to the clinic with a fear of flying. In summary. and often very effective. 1997]. Antony et al. it will not hurt when something touches it. Structured interviews that are disorder specific. active. For example. 1989) and the PTSD Symptom Scale (Foa et al. This history would be more suggestive of a diagnosis of PTSD. serve as another way to track progress over time. Knowing only this information does not establish a diagnosis or a treatment plan. 1994]) are useful tools. Although some clinicians prefer to use an unstructured interview format. Jumping into treatment without first having a very clear sense of the patient’s problems can be frustrating (and even detrimental) for both patient and therapist. time-limited. Behavioral Assessment Conducting a thorough assessment and establishing an accurate diagnosis is a critical first step in treatment planning. rationale-supported. structured clinical interviews (e. (2001) recently edited an excellent volume aimed at helping clinicians to select empirically based assessment measures for anxiety disorders. the goal is the same: to identify the primary problem that should be the focus of treatment and also assess other factors that might be relevant to the clinical picture. Regardless of the specific tools used. are commonly used. and even though it still may leave a scar. 1993). including the Yale-Brown Obsessive Compulsive Scale (Goodman et al. Anxiety Disorders Interview Schedule for DSM-IV [Brown et al. The patient might have actually been on an airplane that made an emergency landing because of engine failure and might have since been experiencing nightmares and flashbacks. Structured Clinical Interview for DSM-IV [First et al. PE is the process of opening up and cleaning that wound and healing it thoroughly. These focused interviews are very helpful for treatment planning and for tracking changes in disorder-specific symptoms over the course of treatment. which can provide useful information in addition to the clinical interview.

Patients are often amazed when clinicians ask questions about these subtle nuances. this patient might feel confident flying with a companion but might be very frightened of flying alone. having a few drinks before getting on the airplane) is very important for the process of treatment planning. Behavior therapists also assess the patient’s general functioning and how it has been affected by the presenting problem.. These distinctions are important because although behavior therapy for the various anxiety disorders certainly shares common features.. when giving up rituals is extremely difficult for patients with OCD. being reminded of how their lives will improve with less OCD in- .g. Furthermore. For example. This makes the patient feel understood and enhances the establishment of a strong therapeutic alliance. Comorbidity is common with many disorders.. For example. Longer flights. It is also important to obtain a full or complete description of the characteristics of feared situations. the treatment approach for each of these causes of fear of flying would be quite different. Getting a sense of the overt avoidance practiced by the patient (e. knowing what the patient hopes to gain from a decrease in symptoms can be helpful later in treatment when he or she is faced with challenging tasks in therapy. Important areas to assess include occupational or educational and social functioning. Additional diagnoses may play a role in the maintenance of a primary disorder (e. This serves as a useful metric for the severity of the disorder and helps in the process of establishing rapport by looking at the whole person rather than focusing on only symptoms. might be a problem.g. This patient would most likely have panic disorder. This type of questioning conveys the therapist’s understanding of the patient’s disorder and his or her particular symptoms. not taking long flights and not flying alone) and more subtle avoidance (e. a person with social anxiety who drinks alcohol as a means of alleviating anxiety in social situations) and also can influence the targets and progress of therapy (e. a person with PTSD and very severe depression accompanied by suicidal ideation may benefit from treatment aimed at amelioration of depression before focusing on the PTSD). patients are also asked about other problems or difficulties that they might be experiencing. however. a patient with panic disorder who (among other situations) fears flying might be fine on a 1-hour airplane ride.g. subtle variables influence the clinical picture of each patient. clinicians should be aware of the bigger picture. In the process of assessment. and although treatment should focus on one disorder at a time.56 The Art and Science of Brief Psychotherapies attack while on an airplane and be uncomfortable with the idea of not being able to leave the situation if this were to occur.. Typically.g. Similarly.

In these instances. a patient whose primary ritual was making things “come out even” was quite distressed in her first exposure session to have only one exposure planned by the therapist for that session. because of contamination fears. During clinical interviews and when completing selfreport measures. many patients have difficulty reporting on the thoughts. having patients undergo a behavioral test in the presence of the assessing clinician can provide valuable information for diagnosis and treatment planning. Interventions In this section. Another patient automatically straightened sheets of paper on the therapist’s desk that were off center. this also can be used as a good measure of treatment outcome. driving through traffic. they can be used in the assessment process. leaving the house. Her compulsion compelled her to insist on doing two of the exposures on her hierarchy. such as asking a patient with a fear of public speaking to give a speech in front of several strangers. . Role-playing a social interaction with a patient can give the assessor a good sense of the patient’s strengths and weaknesses in social skills or assertive behavior. or compulsions may be evident right in the session. having more time to spend with the family) can be very motivating. The major variable of interest in this type of behavioral test is how far along the fear hierarchy the patient can progress. and feelings that they experience when they are faced with their feared object or situation.g. Although behavioral tests are not essential.g. getting in the car. Behavioral tests also can involve assessing how far a patient can progress through a series of actions leading up to a feared behavior. a person with agoraphobia who can no longer go to work may be asked to progress as far along his or her route to work as possible (e. another was reluctant to use the therapist’s pen to fill in self-report measures. Being observant of subtleties in behavior can help formulate a clearer clinical picture. we describe two types of treatment that are frequently used interventions of the behavior therapist: anxiety management training and exposure therapy. Patients with OCD may arrive at sessions very late because they were held up at home with their rituals. For example. Other patients avoid their feared object or situation to such an extent that they may not have a clear recollection of how they reacted in the past when confronted with these feared stimuli. returning to work. For instance. Behavioral tests often involve having patients engage in a feared behavior. arriving at the office)... behaviors.Brief Behavior Therapy 57 terference (e.

behavioral rehearsal or covert modeling.g. for use at home. and the rationale or conceptual groundwork for the skills training is laid down.. structured problem solving. The therapist gives specific instructions for how to slow down breathing and pair it with a cue for calming and relaxing the mind (e. The next phase includes training and practice of coping skills. silently and slowly drawing out the word calm while exhaling very slowing—“caaaaaaaaaaaalllllllllmmm”). including female rape victims with PTSD. medical patients undergoing painful procedures. Stress is experienced when the person views the environment as straining his or her coping resources and thus threatening his or her safety or well-being. The goal of the stress inoculation treatment is to teach patients to understand the dynamics of stress and to develop or enhance their intrapersonal and interpersonal skills for managing stress. Meichenbaum’s well-studied SIT program begins with an initial conceptualization phase in which the patient’s presenting problems are analyzed from the transactional perspective. the patient is enlisted as a collaborator. The therapist models this slow breathing pattern and then observes as the patient tries and provides appropriate feedback.g. an audiotape is made of the therapist guiding the patient through 10–15 such . police officers and firefighters). These typically include breathing and relaxation training to aid in the reduction of physiological arousal and tension. assertiveness training. In Meichenbaum’s description of the conceptual underpinnings of SIT. and role-playing. guided self-dialogue. Some of these skills are described in the following subsections: Breathing Training The therapist explains that the goal of the breathing retraining is to slow respiration rate and reduce oxygen intake. SIT has been used in numerous settings and with various populations. In this model. Anxiety is a normal response to stress. stress is a dynamic. stress is viewed not just as an environmental event or as the individual’s emotional and behavioral response to the event but rather as an interaction between the person and the environment. inevitable aspect of life and cannot be eliminated. workers in high-stress job settings (e. cognitive restructuring. Finally..58 The Art and Science of Brief Psychotherapies Anxiety Management Training (Stress Inoculation Training) The conceptual model underlying anxiety management training stems largely from theories of stress and coping. One of the most commonly used forms of anxiety management training—SIT (Meichenbaum 1984)—is firmly rooted in this framework. and athletes enduring the stress of intense competition.

and 7) evaluate the outcome. the patient is taught to systematically tense and then relax specific muscle groups throughout the body. and an audiotape is usually made of the instructions for the patient to practice with every day at home. For each stage. The patient is taught to prepare for stressful situations by asking and answering a series of questions. Relaxation Training A very commonly used method of relaxation training is the progressive muscle relaxation exercise. Guided Self-Dialogue In guided self-dialogue. and 4) reinforcement. 4) evaluate the pros and cons of each possible solution. facilitative. During progressive muscle relaxation training. The goal of this training is to learn to identify what muscles feel like when they are tense and tight and thus be able to eliminate excessive muscle tension when it is detected. preceded and followed by slow. calm breathing. The therapist teaches the relaxation exercises in session.Brief Behavior Therapy 59 respiratory cycles. For example. the patient learns to focus on his or her internal dialogue or on what he or she “is saying to himself or herself. Structured Problem Solving The patient learns to define and solve problems by following a series of steps. which may include behavioral or imaginal practice of the steps with the therapist. 3) generate a list of possible solutions or alternative courses of action. Most problem-solving strategies require the patient to systematically 1) define the problem in concrete terms. the patient is often taught abbreviated or shortened forms of relaxation. therapists often teach patients in this stage to relax by “focusing in” on each muscle group and “letting go” of tension.” The overall aim is to replace irrational. 3) coping with feelings of being overwhelmed. or negative self-dialogue with rational. Once proficient at identifying and eliminating excess muscle tension. the . 6) implement the plan. 2) set a realistic goal and steps to the goal. The patient is encouraged to practice the skill several times daily in order to develop its use for managing anxiety. 2) confrontation and management. unhelpful. coping with stressors consists of four stages: 1) preparation. including reinforcing himself or herself for attempting to solve the problem. In a version of Meichenbaum’s SIT program adapted by Veronen and Kilpatrick (1983) for rape survivors. 5) choose a solution and determine the steps necessary to implement it. while focusing his or her attention on the tension–relaxation contrast. and task-enhancing dialogue.

increased proficiency in successful management of stress promotes increased confidence and self-efficacy in the patient. 4) engage in the desired behavior. the patient visualizes himself or herself coping successfully with the situation. anger. As noted in our introduction to behavior therapy. sadness) that are associated with high levels of stress typically diminish as the patient’s skills for managing stress .g. The more that a patient practices the new tools outside of sessions. The anxiety and other negative emotions (e. Role-playing is a means of learning new behaviors and words and provides a chance to practice the new behaviors before the real-life event occurs. During the roleplay training. Like a dress rehearsal. roles are reversed so that the patient plays himself or herself. The patient and therapist discuss the experience after each role-play..e. the more proficient he or she becomes and the more data he or she has to bring into sessions for continued fine-tuning of the skills. the patient and therapist actually act out scenes in which the patient confronts a difficult or stressful situation. it is common for the therapist to first play the patient’s role and model appropriate social skills. covert). Typically. 2) manage avoidance behavior.. At the same time. Role-playing is the rehearsing of speech and actions while pretending to be in a particular situation or in a set of circumstances. the therapist first describes a scene involving a difficult situation for the patient in which he or she confronts and successfully works through the situation (i. Covert modeling is imaginal practice of a desired behavior and is essentially role-playing in the imagination (i. Next. and 5) reinforce himself or herself for attempting the behavior and for following the plan. During role-play. with the goal of shaping desired behavior and developing better skills through practice. The patient is encouraged to point out positive aspects of his or her performance as well as areas that could be improved. Behavioral Rehearsal Two common methods of rehearsing new and developing behaviors are covert modeling and role-playing.60 The Art and Science of Brief Psychotherapies patient and therapist generate a series of questions and statements that encourage the patient to 1) assess the actual probability of a negative event happening.. modeling). Role-plays are repeated. Scenes used for covert modeling are sometimes those later used for role-play practice with the therapist. and the therapist also gives feedback. the repetition of a behavior reduces anxiety and makes it more likely that a new behavior will be used when it is called for. homework and repeated practice of newly acquired skills are integral to this approach. Then.e. 3) control self-criticism and self-devaluation.

The avoidance ultimately causes so much interference in the man’s life that he finally seeks treatment for his phobia. The sight of a dog walking down the street reminds him of the dog that bit him (stimulus–stimulus association). makes him begin to just stay at home. and he immediately associates this unfamiliar dog with danger (inaccurate association of stimulus with meaning of danger). intervention must 1) activate the fear structure and 2) provide new information that is incompatible with the existing pathological elements so that they can be corrected. . not leaving until he is sure that the dog will be gone. new learning) to be integrated into the person’s representation or memory of this situation. This association triggers extreme fear (disruptive intensity) in the man. Another very effective means of decreasing anxiety is learned in the process of exposure therapy. Consider the example of a man who is bitten by a stray dog one day and subsequently develops a fear of all dogs. building on the work of Rachman (1980). proposed that in order for treatment to successfully modify a pathological fear structure. This scenario is repeated every time the man encounters a dog. response. his muscles tense and his body trembles. His fear. and how can it be modified? According to Foa and Kozak (1986). His heart rate and respiration accelerate rapidly.Brief Behavior Therapy 61 improve. Exposure Therapy Excessive and persistent fear is a core feature of anxiety disorders. Yet fear is certainly a normal and appropriate response to dangerous or threatening situations. and meaning elements. He has a hard time believing that this particular dog is friendly and safe and has never bitten anyone. even at a distance. continually reinforced by this persistent and pervasive avoidance of dogs and any place a dog might be encountered. despite repeated reassurance (resistance to modification). How can the clinician help this patient to decrease this pathological fear? Foa and Kozak (1986). pathological fear is distinguished from normal fear by its disruptive intensity. Exposure procedures activate the fear structure through direct or imaginal confrontation with the feared situation or object. He immediately runs to the nearest building (association between harmless stimuli and avoidance responses).. by the presence of inaccurate associations among stimuli. Exposure therapy has proven to be a very effective means of accomplishing both of these objectives. What distinguishes normal or appropriate fear from pathological fear? How can we conceptualize clinically significant fear. and by its resistance to modification. This confrontation provides an opportunity for corrective information (i.e. and he breaks out in a sweat.

feelings. Imaginal exposure is most commonly used in the treatment of PTSD and OCD. the therapist provides a thorough rationale for its use in ameliorating PTSD symptoms. until the anxiety and distress associated with the memory have subsided. Imaginal exposure is continued for a prolonged period (usually 30–45 minutes) and includes multiple repetitions of the memory if necessary. patients are encouraged to confront the feared and avoided situations or objects in two main ways: 1) imaginal exposure. the patient is asked to listen to audiotapes of the imaginal ex- . Imaginal Exposure In imaginal exposure. imaginal exposure or reliving is used to help the patient to emotionally process and organize his or her traumatic memory. the patient is instructed to close his or her eyes and describe aloud what happened during the trauma. the patient and therapist discuss the experience. The goal is to help the patient access and emotionally engage in the trauma memory.62 The Art and Science of Brief Psychotherapies thus lessening the fear associated with it. Once begun. For homework. if the man with the dog phobia repeatedly approaches and pets dogs that wag their tails and do not bite him. The therapist explains to the patient that imaginal exposure to the trauma memory promotes emotional processing of the traumatic experience. realization that the memory itself is not dangerous and that anxiety does not last forever. which entails systematic and gradual confrontation with objects. Imaginal exposure for treatment of PTSD. habituation of distress when thinking about the trauma. In imaginal exposure. the patient vividly imagines himself or herself coming into contact with the feared situation or stimulus. Immediately following the imaginal exposure. For example. The imaginal scene typically includes a detailed description of events as well as the thoughts. places. and increased confidence in one’s competence and ability to cope. or activities that will trigger fear and urges to avoid. This results in increased coherence and organization of the memory. then he will learn that some dogs are safe. In PTSD treatment. In exposure treatments. which requires the patient to vividly imagine the feared situation and its consequences and to not avoid or escape the resulting anxiety. and physical sensations the person imagines would result from that contact. situations. Before initiation of imaginal exposure. the imaginal exposure is conducted in multiple treatment sessions. The patient uses the present tense to describe the thoughts. while visualizing it as vividly as possible. and sensory experiences that occurred during the traumatic event. and 2) in vivo exposure. emotions.

When I go out to investigate.Brief Behavior Therapy 63 posure on a daily basis. Next. I think of the pesticides the kids had been running through. which is written in the present tense and includes a great deal of elaborate sensory and affective detail to enhance the vividness of the story. Before beginning the imaginal exposure. As I’m finishing and putting the equipment away. Instead. They are playing a game and are darting in and out through the bushes. the patient engages in the imaginal exposure by vividly imagining this event and its consequences while describing aloud the scene he or she is visualizing. the therapist and patient together develop the details of the imaginal scenario. I decide to give everything an extra-heavy coating because it’s been so long since I did it last. The session is tape-recorded. I hear a loud disturbance and see flashing lights outside. I feel a twinge of anxiety as I think about the pesticides and worry again that it could be dangerous to the kids. I decide it’s not worth the trouble and do not bother. and the patient is instructed to listen to the scenario over and over and to imagine the events described as though they were happening “right now. the emergency team will need to know this. I hear the sound of children from behind me.” Imaginal exposure is conducted over a prolonged interval and over several successive days to achieve habituation and extinction of the fear. but I don’t have the energy to yell that loudly. the same house where the children live. In OCD treatment. I see police cars and ambulances on the street in front of the neighbors’ house. coating every surface until it drips onto the ground. B. Later that night. I find the children’s parents and feel a knot of fear growing in my stomach as they . Imaginal exposure is often an effective means of confronting feared situations and their unrealistic or excessive consequences. imaginal exposure is used primarily as a means of exposure to the feared consequences of obsessions or of not performing compulsive behavior. which continues the work of emotionally processing of the trauma. an OCD patient with harming obsessions. so again I shrug it off and turn to go into the house. Imaginal exposure for treatment of OCD. I notice the fluid collecting on the leaves of the shrubs and on the grass. and I turn to see two kids running through the yard where I just finished spraying. The following is an example of an imaginal exposure script for Mr. I fill up the sprayer with pesticides and go out into the garden to spray the yard. Once again. and it occurs to me with a sudden rush of dread that if they have been poisoned. I consider telling the kids to stay away. Note that the imaginal narrative clearly aims to promote engagement with the OCD patient’s feared consequences (killing innocent children through his careless handling of chemicals and going to jail for life for this). The sight of the poison dripping from the leaves triggers a moment of fear as I think about how it could be dangerous or deadly to someone and that maybe I should put up signs to warn people.

flanked by several stern-looking police officers. damp. and I am very worried.64 The Art and Science of Brief Psychotherapies tell me that the children have fallen mysteriously ill with severe rashes and stomach pain and that they may die. the audience. and I turn to see my wife looking at me in shock. I am quickly found guilty and sentenced to life in prison. I think of what my future holds: living in a dark. but I don’t say anything. beginning with items that have been assigned moderate subjective units of distress ratings and working up through the list to more feared items. among hardened criminals and being forced to endure a lifetime of violence and brutality. A well-constructed hierarchy includes a range of items spanning from those that generate moderate anxiety to those that generate the most anxiety a patient can imagine (see Table 3–1). and when I open it. In Vivo Exposure In vivo exposure refers to real-life confrontation with feared stimuli as opposed to confrontation in imagination. “Is it true? Did you really kill those poor children? How could you?” My case quickly comes to trial. I see the children’s parents with tearstained faces. and in front of the entire courtroom. witness after witness testifies to how I recklessly sprayed a deadly pesticide all over my yard and knowingly allowed children to play in it. I am awakened by a loud banging on the door. that not one person is on my side. patients are asked to assign a subjective units of distress rating (ranging from 0 to 100) to each item as a means of arranging the items in a hierarchical order. The first step in implementing in vivo exposure is to create an exposure hierarchy: the patient and the therapist work together to generate a list of situations or activities that the patient either endures with great discomfort or avoids completely. I feel completely helpless and terrified as I am led away. This approach allows patients to gain confidence and self-efficacy through early success experiences and is also more palatable than starting exposure exercises with the most anxiety-provoking items on the hierarchy. As I am led away. This is how I will spend my last years. saying. who promptly place handcuffs on me and inform me that the children died during the night and that I’m under arrest for manslaughter because of my reckless behavior. The first exposure typically takes place during a treatment session so that the therapist can demonstrate the process of exposure and lend sup- . Once the list is generated. and I know that I will never see them again. and even my own family. In general. filthy with urine and waste. I realize that I am completely alone in that courtroom. disgusted expressions on the faces of the jury. it is best to confront the items in a systematic way. smelly cell. The next morning. I look around from where I am seated and see the angry. I see my family looking at me with disgust. thinking that I don’t want to be held responsible and hoping that the doctors will know what to do. I am now certain that the kids are poisoned from the pesticides.

asking a stranger a question). and it is important for patients to see that they can confront their feared situations on their own and effectively manage their anxiety. In the other anxiety disorders (e. patients may credit success experiences to the benevolence of the therapist or others involved in the exposure. For example. It is also essential that patients begin to do exposures on their own in between sessions as soon as the first in-session exposure is completed.Brief Behavior Therapy 65 Table 3–1.. Duration of exposure to feared situations is an important factor. Exposure should last long enough for anxiety to habituate. rambunctious dog who likes to jump on people Go to dog park in city where dogs have to be on leashes Go to dog park in city where dogs can run freely port and encouragement for this challenging task.” If a patient fears riding elevators in skyscrapers. In the case of social phobia. he or she could go to . a good early exposure would certainly be to ride the elevator in the therapist’s office building.g.g. Some patients discount success experiences that occur during in-session exposures. As such. OCD. clinicians are seen as “safe” people. the exposure should be repeated numerous times. If an exposure is by nature very short in duration (e. treatment sessions should rarely be less than an hour and might even need to last for several hours. if a patient with social phobia fears saying hello to people (a behavior that takes just a few seconds). Yet treatment will be most effective if a later session is held in a skyscraper to directly confront the patient’s specific fear.. panic disorder). In-session exposures are not limited to the clinician’s office but rather take place where the anxiety “lives. Sample hierarchy for specific phobia of dogs Subjective units of distress rating 30 35 50 55 60 65 65 75 80 85 90 100 Item Look at Dogs Illustrated magazine Watch movie about wild dogs Go to mall and look at dogs through front plate-glass window of pet store Sit in therapist’s office with small dog (on leash) Pet small dog with therapist holding on to leash Sit on floor of office with dog walking freely around office Refrain from crossing to other side of street when people walk by with dogs on leashes Go to pet store where people walk around with their pets on leashes Go to pet store and ask to pet and hold specific dogs Visit friend who has large.

see p. it might be appropriate to spend one session (or part of a session) doing imaginal exposure. Flexibility and creativity on the part of the clinician are necessary when setting up exposures for the treatment of phobias. driving during rush hour. Even in these situations. In vivo exposure is preferable to imaginal exposure in the treatment of phobias. the therapist and patient can ride in . Imaginal exposure also can be used for phobic stimuli that occur infrequently (e. readers are referred to Antony and Swinson (2000. However. where they can ask questions in front of strangers. such as a book reading. it can be helpful to add intermediate steps to the hierarchy. thunderstorms) or that are logistically difficult to implement on a regular basis (e. In vivo exposure for treatment of phobias. A patient who has a fear of public speaking can practice an impromptu speech in front of the therapist and office staff. In vivo exposure for treatment of panic disorder. Similarly. In the case of social phobia. People with panic disorder frequently fear enclosed places. it would be best to advise him or her to come back for treatment during the spring or summer. particularly because the feared situations of people with social phobia are amply available.. In such cases. For example. Other common exposures include riding the elevator. in vivo exposure must be a part of treatment. If a patient who lives in the North presents for treatment of a phobia of thunderstorms during the winter.66 The Art and Science of Brief Psychotherapies the mall and say hello to the clerk in every store. so even sitting in the clinician’s small office with the door closed can be a useful exposure.. patients who are being treated for a fear of flying must be committed to taking at least one flight at some point in treatment. however. For additional guidelines on how to conduct effective exposures. in vivo exposure is always preferred to imaginal exposure. For example. Therapists also can accompany patients with social phobia as they return an item of clothing to a store or attend a public event. Role-plays can be set up in which patients practice asking people out on dates. imaginal exposure is rarely used in the treatment of panic disorder. Situations feared by patients with panic disorder are typically readily available.g. 199). if patients are extremely fearful at the beginning of the exposure phase of treatment. riding the subway. or going for a job interview. As in the case of social phobia. standing in lines. flying). Some patients with panic disorder have difficulty transitioning from insession exposures in the presence of the “safe” therapist to doing homework unaccompanied. having casual conversations.g. our patient who is very afraid of dogs can be asked first to imagine petting a dog before moving on to actually doing it in vivo. and going to crowded supermarkets.

a better exercise is to touch the doorknobs and light switches and then shake hands with office staff or offer them a snack that the patient must handle. going to an empty parking garage alone late at night). an exposure might involve touching doorknobs and other objects around the office and then refraining from washing before eating food. the therapist goes to the patient’s home for a session and helps him or her to leave the house without checking the locks. and objects that remind them of the trauma. For a patient who fears getting ill from germs. For example. Home visits are often an important component of treatment of OCD. Trauma survivors often avoid places. other in vivo exposures are very beneficial in the treatment of trauma. it is beneficial to have a session at home that is focused on contaminating objects there. a patient who survived a car crash may avoid driving his or her car whenever possible. In vivo exposure for treatment of PTSD. With this caveat in mind. Certainly. The goal of EX/RP is for patients to expose themselves to feared situations and to learn that anxiety will habituate without the use of compulsive behavior. In vivo exposure for treatment of OCD. therapists should remind them of the importance of complete ritual prevention before the exposure begins as well as during the exposure itself.. This exercise might make it easier for the patient to then ride the subway alone. Exposures for patients with OCD vary greatly given the heterogeneity of symptoms seen in the disorder. Specific to OCD is the use of exposure combined with prevention of rituals or compulsions (EX/RP). It is particularly important in OCD treatment to be aware of subtle rituals that patients might use to alleviate anxiety. This is helpful early in treatment.g. people. There is no need for victims to confront the perpetrator of a crime or to go to the place where the trauma occurred if that place is objectively considered unsafe (e. If a patient was assaulted in a hotel and now . For patients who use mental rituals or whose behavioral rituals are very subtle. In vivo exposure is an essential component of treatment for most patients with OCD. If patients have difficulty leaving the house because they worry about forgetting to lock the door. exposure to feared stimuli that are realistically dangerous or high risk is not appropriate or beneficial. For a patient who fears making others ill by spreading contamination. For patients with contamination fears whose homes are considered “safe” places. patients sometimes do exposure homework accompanied by a friend or family member.Brief Behavior Therapy 67 separate cars of the same subway train and arrange to get off at a particular station. Similarly. A reasonable goal of treatment is to get the patient back behind the wheel. but such safety nets are gradually phased out as treatment continues.

parking lots or other public . OCD (e. 212) identified which physical symptoms are most strongly experienced during particular symptom induction exercises. we strongly suggest that exposure therapy be conducted under close supervision with an experienced exposure therapist.g. one of our patients tried unsuccessfully to use a telephone to call for help.g. breathing through a straw. p. and the assailant tried to strangle her with the telephone cord. running in place. Interoceptive Exposure Interoceptive exposure is a technique most often used in the treatment of panic disorder. dogs).68 The Art and Science of Brief Psychotherapies avoids being in any hotel. or hyperventilate. However.. Roth. as a general rule. could be asked to spin around in a swivel chair. hyperventilating). they need not be feared or viewed as a sign of imminent catastrophe.. patients do things that will deliberately induce feared physical sensations (e. the therapist must convey confidence in and comfort with the exposure model and with exposure exercises. we discuss common sources of such discomfort and our suggestions for dealing with them. and Swinson (see Antony and Swinson 2000. Symptom induction exercises should be used that tap into the patient’s specific concerns. for example. Common Concerns and Caveats in Conducting Exposure Therapy The conducting of exposure therapy often provokes anxiety in novice therapists.. Patients who are fearful of the sensation of dizziness or light-headedness. In vivo exposure for simple phobia (e. Following the trauma. it is reasonable to incorporate that into treatment. it is quite reasonable to help patients learn to be less afraid of these sensations. PTSD (e. which are. of course. not dangerous. The goal of interoceptive exposure is to help patients learn that although some physical sensations might be uncomfortable. contamination). In this form of exposure. Her in vivo exposure exercises included making calls from telephones with cords. lest his or her own hesitation instill doubt in the patient and undermine treatment. During a kidnapping. particularly because it requires the therapist and the patient to confront a degree of risk with which neither may be entirely comfortable. Certain objects also might come to be associated with fear. Antony.g. Given that panic has been conceptualized as a fear of bodily sensations (Clark 1988). Risk to the patient.g. she would only use cordless telephones. shake their head from side to side. In the following subsections..

The general rule of thumb we use in deciding what constitutes appropriate exercises is to consider whether the proposed activity is something most people would do or consider reasonable. rather than attempting the impossible task of completely eliminating danger. would a reasonable person do the exercise if circumstances necessitated it? For example. most people would do so.. that is.. walking on a crowded. living requires making informed decisions about everyday risks and learning to accept small risks. Therapist and patient alike must contend with the reality that very few activities in life are completely free of risk. although most people might not routinely put their hands into a toilet in the normal course of events. Sometimes therapists express hesitation to assign certain in vivo exposure exercises because they fear risk to themselves or because they would not themselves be willing to complete the assignment. touching them.e.g. if a therapist is not particularly fond of spiders and is getting ready to treat a person with a specific phobia of spiders. hesitate to accompany someone who has a driving phobia on an in vivo exposure exercise for fear of an accident or may be reluctant to conduct certain harm.Brief Behavior Therapy 69 places).or contaminationrelated in vivo exposures for OCD because they fear being harmed or made ill themselves. the therapist becomes much more comfortable with them. if one were to drop something important into the toilet. Risk to the therapist. letting them crawl on his or her hand) so that confidence rather than discomfort or fear is modeled for the patient. For instance. Therapists may. At our . after training and practice with such techniques. for example. For most of us. he or she might want to spend some time getting used to spiders (e. or having an accident). and panic disorder (e. and thus we usually apply a different standard for ascertaining “acceptable” risk. deserted street in a dangerous neighborhood would likely be considered unacceptably risky. being assaulted. whereas walking on a dark. In the case of designing exposure exercises for OCD. The best remedy for these doubts is experience. however. we have found that exposure often needs to go beyond what “most people” typically do. therapists might even want to do an exposure on their own a few times before doing the exposure with the patient.. driving) may entail some degree of risk to the patient (i.g. becoming ill. busy street in the daytime might be considered a reasonable in vivo exercise. being bitten. In vivo exposure for patients with PTSD often involves helping to return to former levels of behavior or activity. For example. Because these judgments are often difficult to make without the benefit of experience in conducting this form of therapy. the beginning behavior therapist is strongly encouraged to use supervision for help in making such judgments. In some cases.

and close supervision is critical for less experienced therapists. true pedophilia is more likely (although not necessarily certain). they make great efforts to avoid cues that might increase the likelihood of acting on these unwanted and feared impulses (e.e.. this is more likely when the fear is the product of some real or imagined threat from another person. Finally. Although homicidal ideation may be accompanied by fear. a careful assessment.70 The Art and Science of Brief Psychotherapies clinic.g. some behavioral or mental ritual intended to neutralize the impulse usually accompanies harming obsessions. OCD vs. Moreover. the fear that one may suddenly and impulsively harm another person. whereas homicidal ideation tends to be volitional and goal directed. rage. the principal affective response to harming intrusions is fear or distress. accompanied by the therapist. we eat a bit of the food regardless of whether we are hungry. is always indicated in advance of treatment planning. If sexual arousal is part of the clinical picture. In OCD. those involving harming obsessions or obsessions of a sexual nature. Certain forms of OCD often raise particular concerns among professionals—namely. For example. when a patient in our clinic. Certainly.. therapists often notice that their own anxiety about certain activities habituates after guiding patients through them several times. Another source of concern involves the use of confederates in exposure treatment. or satisfaction. many professionals may reasonably worry whether these patients pose a risk to others. When assessing OCD patients with harming obsessions (e. . including a thorough history. perhaps by grabbing a knife and stabbing him or her) or sexual obsessions (particularly pedophilic obsessions). If anything. Several features distinguish harming obsessions from homicidal ideation. offers one some kind of unwrapped food to eat.. an important distinction is whether the pedophilic intrusions are accompanied by sexual arousal and a desire to act on them. are ego-dystonic). and the homicidal thoughts are driven by a desire for self-protection. This dilemma is basically one of differential diagnosis (i. it is likely that this patient is offering food that he or she fears is contaminated.g. Being helpful colleagues. When distinguishing between OCD with pedophilic content and true pedophilia.e. whereas true homicidal ideation is more often accompanied by anger. especially when intended to provoke harming obsessions. and exposure should be terminated if the exercises consistently provoke sexual arousal. OCD patients with harming obsessions very seldom have any history of violence or of having taken steps toward implementing their intrusive impulses. homicidal ideation or pedophilia). Risk to others. Harming obsessions are experienced as involuntary intrusions that are inconsistent with the patient’s self-image (i. removing all knives from the house)..

washing hands. As described earlier in this chapter.g. When enlisting a particular person as a confederate. C. Research has shown that combining exposure and ritual prevention produces more overall improvement than either component individually. voluntary exposure to stimuli that provoke anxiety (e. For example.. the other key component. we present two of the exposure-based treatment programs developed and extensively studied at the CTSA: EX/RP for treatment of OCD and PE for treatment of PTSD. C. handling garbage to confront fears of contamination by germs). Mr. Ritual prevention. Two Exposure-Based Behavioral Treatment Programs In this section. checking something repeatedly). however.Brief Behavior Therapy 71 Confederates who are unfamiliar with the patient’s particular fears (and thus in the patient’s eyes more likely to be caught unawares by the patient’s “harmful” behavior) are very useful in treating harming obsessions. an exposure exercise. wearing gloves. it is generally accepted that total abstinence from rituals is optimal and that patients who retain much of their ritualistic behavior during and after treatment are at greater risk for relapse (Kozak and Foa 1997. would be conducted only if the family member understood the point of and agreed to participate in the exercise. EX/RP involves systematic. the therapist should ensure that the person understands the rationale for EX/RP. The loved one needs to be fully informed as to the nature and intention of the exercise and given the opportunity to decline any part with which he or she is not comfortable. a 26-year-old man. using disinfectant. .. primarily involving fears of contamination. as was the case with Mr. presented with severe OCD.g. Although less research has addressed the question of the optimal level of ritual abstinence needed for successful outcomes. Riggs and Foa 1993). especially with the AIDS virus or carcinogens. such as the patient holding a sharp knife while sitting next to a loved one. The involvement of loved ones in exposure therapy for harming obsessions may be essential when the patient’s core fear is of harming those closest to him or her. Exposure and Ritual Prevention Treatment Program for Obsessive-Compulsive Disorder EX/RP is the psychotherapy treatment of choice for OCD. is the voluntary suppression of the usual ritualistic response or compulsion (e.

as illustrated in the case of Mr. Throughout his intensive (daily therapy) treatment course. he was persuaded to give up this particular ritual as one of his weekly exposure exercises. Similarly. one week he refrained from washing his hands after urinating. but approximately 2 months after completing treatment. At the end of treatment. and using disinfectants) were so pervasive and extreme that he was neither able nor willing to comply with complete abstinence from rituals. After successful implementation of this change. B. touching objects and surfaces in an adult peep show). illustrates this point. on most of these occasions. Mr. sharing a drink with a male confederate Mr.g. Thus. for example. However. D and his therapist instead incorporated gradual ritual prevention in specific situations into his exposure hierarchy. Therefore. Mr. often going beyond what the therapist expected he would have been capable of (e. D. a 67-year-old man. The case of Mr. he had relapsed to his pretreatment level of severity. introduced earlier. although initial imaginal exposure appears to improve the effectiveness of subsequent in vivo exposure. C’s distress resulting from obsessions was improved. D then refrained from rinsing his hands after urinating. such as repeating the phrase “minimal risk” under his breath to reassure himself that the exercise would not result in harm. Mr. Research generally suggests that exposure in vivo is more effective in reducing OCD symptoms. C was observed to engage in covert or near-covert rituals. substituting instead a simple rinse of the hands. the addition of imaginal exposure to the feared consequences of subsequent in vivo exposure appears to produce better long-term outcomes. On a related issue. meaning that he remained unconvinced throughout treatment that his fears were unrealistic. An interesting question concerning implementation of EX/RP is whether treatment must include actual physical contact with feared stimuli (in vivo exposure) or whether imaginal exposure is sufficient to achieve symptom reduction. Mr.72 The Art and Science of Brief Psychotherapies He had relatively poor insight. D experienced such intense anxiety after defecating that he was unable to refrain from showering. eventually. C believed to be homosexual. Although it is most common for patients undergoing EX/RP to be instructed to abstain from rituals completely from the beginning of treatment. Mr. rituals may be eliminated on a graded schedule. however.. showering. In vivo exposures included activ- . this “cold turkey” approach is sometimes unrealistic for patients with severe OCD. In such cases. he completed exposure exercises diligently. Mr. his avoidance and rituals (including washing. presented with harming obsessions that involved causing illness or death to others by inadvertently poisoning them with household or industrial chemicals. D was a 50-year-old man with severe contamination-related OCD. Mr. B.

Certainly in some cases. using exposures of long duration over consecutive days. Stan was encouraged to purposely expose himself in imagination to the sexual images he reported experiencing spontaneously. consisting of 17 sessions in total.g..or 2-day home visit is sometimes scheduled to ensure generalization of treatment gains to the home environment. B’s distress when actually using pesticides was significantly diminished. In vivo exposures were conducted in situations that Stan avoided because of these fears (e.g. looking at magazines that contained attractive male models.g. Taken together. driving in cars. many of Stan’s exposure exercises were conducted in imagination.. however. treatment outcome studies suggest that the optimal behavior therapy for OCD involves both exposure and ritual prevention components. in vivo exposure is impractical or unethical (e. and end with homework assignment. therapist-supervised exposure sessions that are conducted either in the office or in whatever setting (e. a script was developed in which children in his neighborhood became ill and died as a result of his having sprayed pesticides in his garden (see the earlier subsection “Imaginal Exposure for Treatment of OCD” for an example of an imaginal exposure script). These exercises were greatly enhanced by the addition of imaginal exposure. has the following structure: The first 2 sessions are devoted to detailed information gathering and treatment planning. In keeping with these findings.Brief Behavior Therapy 73 ities such as handling household chemicals in proximity to food or using pesticides in his yard. and instructing the patient to completely resist rituals. because of the ethical and legal problems inherent in conducting in vivo exposure to sexual stimuli. These assessment and planning sessions are followed by fifteen 2-hour.. in such cases. often in combination with the in vivo exercises he was engaged in. the OCD behavior therapy program typically conducted at our center. The sessions begin with homework review. if home visits have not already been conducted during the course of therapy. are typically followed by 45 minutes of imaginal exposure and then 45 minutes of in vivo exposure. a 1. speaking face-to-face with a male peer. home. For example. with therapist-supervised exposure sessions including both imaginal and in vivo elements. Mr. . As a result of listening to this scenario numerous times. exposure to naked children for a patient with obsessive fears of being a pedophile). public bathrooms) might be necessary to maximize the effectiveness of the exposure exercises. Stan was a 15-year-old boy with OCD whose symptoms included intrusive sexual images and thoughts that he was homosexual. For example. At the end of this treatment phase. imaginal exposure may be sufficient to activate the patient’s fear network and accomplish habituation. or watching television shows with attractive male actors).

Her intake evaluation indicated a moderately severe level of OCD. which had led to a significant estrangement from her son. 2-hour sessions.g. stoves. and pushing someone in front of a train. presented for treatment with symptoms consisting principally of harming obsessions. Case Example: Ms. She also reported frequently checking various areas for safety (e. it can be logistically difficult. Despite these and other attempts to minimize contact with stimuli that might trigger her obsessions. intrusive images and impulses involving harm to other people and experienced distress to the point of tearfulness on a daily basis in response to her fears. and sisters. E’s compulsions were primarily mental. She feared that she would impulsively and purposefully injure or kill another person. A commonly used format consists of two 2-hour sessions per week. locks). was avoiding ordering steak or other foods that might require use of sharp utensils in restaurants. E Ms. with whom she had previously been very close.. and was avoiding contact with household chemicals.. OCD treatment at the center is conducted in less intensive formats. seeking reassurance from others that she had not actually caused harm. and frequently expressing her love for others to reassure herself that she would not actually harm them. To illustrate the EX/RP program. Ms. Ms. parents. E. which ultimately led her to admit herself to a hospital on the advice of a psychologist who was concerned that she might pose a threat to others. she reported that she had discarded all knives from her home. She presented for behavior therapy in our treatment center several months after her discharge.74 The Art and Science of Brief Psychotherapies The intensive treatment program offered at our center involves 3 consecutive weeks of daily. For those patients whose symptom severity does not warrant daily treatment or who are unable to devote such a concentrated amount of time. . After living with OCD in various forms for many years. arson.g. age 53. involving the use of ritualistic imagery that would temporarily neutralize her fears (e. She also avoided close contact with loved ones for fear of harming them. imagining herself standing in a purifying white light). E had frequent. Although intensive treatment is powerful in that patients see change in their behavior very rapidly. The means by which she feared doing so varied considerably but included stabbing. poisoning. At the time she entered treatment. we present the following detailed case description of an OCD patient treated with the twice-weekly session format. It is most commonly provided to individuals with very severe and sometimes crippling OCD who are unable to work or attend school because of the interference of the symptoms or to those who come from out of town just for treatment. was avoiding travel by train and subway. E had experienced an acute exacerbation of her symptoms approximately 1 year previously. Ms. She also feared impulsively poisoning her pets and breaking valuables.

Partial exposure hierarchy for Ms. Ms. For feared consequences that were not associated with any particular environmental trigger. places. objects. riding subway with son Choosing the “dark side” Subjective units of distress rating 55 65 90 90 80–90 99 99 100 Because the ultimate goal of EX/RP treatment is to assist the patient in confronting and successfully habituating to his or her greatest fear. This is because often in OCD treatment. and situations that trigger obsessional fears. Many of the in vivo exercises were therefore preceded by exposure to various imagined scenarios in which she actually carried out her intrusive impulses. E’s hierarchy: the idea that she might “turn over to the dark side” and embrace evil forever. it is essential to identify the patient’s feared consequence of exposing himself or herself to this situation. particularly those stimuli that are actively avoided. many in vivo situations represent proxies for still greater underlying fears. and left to rot in prison for the rest of her life. This information is then used to construct a hierarchy for exposure that forms the basis for the treatment. a patient with obsessive-compulsive disorder Situation Standing behind someone on subway platform Buying a knife Handling knife in office in front of therapist Carrying knife in purse. E was instructed to monitor carefully all compulsions on a daily basis to heighten awareness of them. shunned by her loved ones. including a detailed examination of all people. E’s exposure hierarchy is presented in Table 3–2. treatment of OCD begins with a careful and detailed assessment of the patient’s symptoms. E. E’s fear that handling knives in the presence of her son might cause her to murder her son led to a whole chain of feared consequences: she would then be arrested. Ms. to identify environmental triggers that might have been overlooked in the initial assessment. Ms. This was the case for the top item on Ms. For example.Brief Behavior Therapy 75 As described earlier in the chapter. In addition to construction of the in vivo hierarchy. and to begin the process of rit- . keeping knife at home Handling household chemicals Lighting matches and candles Handling knives. Table 3–2. imaginal exposure was conducted in isolation.

and she was reluctant to stand close to the therapist. and exposure exercises were initiated in session 3. for a total of about 60 minutes. Ms. washing. in Ms. By the next session. this exercise was therefore repeated during the evening rush hour (with trains appearing about once every 90 seconds). and the peak level of distress experienced before engaging in the ritual.76 The Art and Science of Brief Psychotherapies ual abstinence. asking for reassurance from others) but also the amount of time spent. but after several minutes. they were initially difficult for her to monitor and control. as a covert means of provoking her obsessional fears. however. imaginal exposure was again paired with in vivo . E had no knives in her house). Session 5 involved the therapist and patient visiting a kitchen supply store to shop for knives (as mentioned earlier. E to covertly augment the exercise with imaginal exposure. The planning stage of Ms. The therapist therefore accompanied Ms. E’s rituals were primarily covert (mental) rather than overt (behavioral). E’s treatment was completed by the end of session 2. she reported substantially reduced anxiety on the subway and was ready to proceed to the next item on her hierarchy. She and the therapist continued in this fashion for approximately 35 minutes. the stimulus that triggered the ritual. As a follow-up to this exercise. Ms. Monitoring of and then abstinence from mental rituals require a degree of self-awareness that patients achieve with varying degrees of success. E’s distress peaked at approximately 90 subjective units of distress and declined to approximately 40 by the end of the session. it was agreed that she would leave the knives with the therapist until the next session. because it appeared that having the knives in her home would be too difficult for her to accomplish at this stage. Ms.g. Because Ms. Ms. As determined by her exposure hierarchy. The monitoring of rituals is highly detailed and requires that the patient note not only the specific ritual engaged in (e. Ms. after which she had experienced only minimal reductions in distress. Because of the public nature of this exercise. During this session. and they stood at the edge of the platform.. In the next session. E’s distress was extremely high. In the next session. it was important for Ms. Initially. with the patient standing behind the therapist. so she was instructed before entering the store to imagine her worst fear throughout the visit: losing control and impulsively stabbing the therapist or shopkeeper. selfmonitoring was relatively easily accomplished. E’s first in vivo exercise involved standing on the subway platform to confront her obsessive fear that she might push someone into the path of an oncoming train. E purchasing one large and one small knife. The exercise terminated with Ms. checking. E’s case. E to a subway station. she was able to stand directly behind the therapist as he stood at the edge of the platform. She was encouraged to select and handle several large and dangerous-looking knives and to test the blade and tip for sharpness to enhance the vividness of the exercise. E was instructed to ride the subway daily and to stand near other passengers on the platform while waiting for the train.

E and the therapist first provided her son with a careful explanation of OCD and of the treatment rationale. including Ms. E felt “ready” to take the knives home. and college-age son. Ms. As treatment approached the top of Ms. to trigger her obsession about causing a fire. E had experience with several scripts prepared by the therapist. E mentioned that she derived some comfort from the knowledge that the therapist was aware of her obsessions and thus might be prepared to defend himself should she “snap” and actually attack. this time Ms. followed by handling food directly. Ms. she was instructed to ask her son to accompany her to two sessions so that he might act as a confederate in several exercises. As described earlier. thereby ensuring constant exposure and habituation to having knives in the house again. By the end of treatment. In these sessions. This exercise required that Ms. At this point. such as 1) inviting separately a friend and then her son to her home and using her new knives in their presence and 2) inviting her sister to sleep overnight and then lighting candles after her sister went to sleep. Because Ms. in which various other people and stimuli of gradually increasing threat were used. In later sessions. including the highly automatic mental rituals she had engaged in with such frequency. E elaborate extensively on her notions of what it would mean to be evil and what the consequences would be for herself and her relationships if this occurred. and she was instructed to use them regularly and to store them in the open in her kitchen so that they would always be in sight. E’s constructing and then implementing a script for imaginal exposure to her most feared consequence—that she would “turn over to the dark side” and become evil. and various household chemicals were used around food. E’s close friend. Ms. in preparation for her taking over responsibility for maintenance of her treatment gains after completion of therapy. she repeated this last exercise with a confederate of the therapist who was not informed as to the nature of her obsessions and whose back remained to her throughout the exercise. she was encouraged to develop her own script in this case. Ms.Brief Behavior Therapy 77 exposure. Therefore. touching the point to his chest. E’s hierarchy. E was encouraged to handle a knife in close proximity to the therapist. including pointing the knife at the therapist. She reported having completely given up her rituals. The exercises conducted in these sessions closely resembled those conducted with the therapist. and making stabbing motions in the air behind his back. Several subsequent sessions focused on this same theme of harming. she was encouraged to do in vivo exercises. These exercises resulted in a reduction in distress from a peak of 98 to a low of 49 at the end of the session. sister. Ms. including standing on the subway platform and handling knives in her son’s presence. The final sessions of treatment consisted of Ms. E’s OCD symptom severity was greatly reduced and fell within the normal range for nonclinical samples. so that he could provide informed consent to his involvement in the procedures. E first approached these exercises through the use of imaginal exposure and then eventually followed up with in vivo exposure with each of the scenarios involved. Although .

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Ms. E continued to experience occasional intrusive impulses and images that caused some distress, she responded to these by either ignoring them or, if this proved unsuccessful, contriving some kind of imaginal or in vivo exposure exercise to combat them. She reported that this strategy was highly successful, and she enthusiastically reported a high degree of confidence that she would continue to be able to manage her OCD effectively.

Prolonged Exposure Treatment Program for Posttraumatic Stress Disorder
Our current PE therapy program for treatment of chronic PTSD consists of 10 individual 90-minute sessions. The goal of the treatment program is to help the patient acquire and master specific skills that are used to ameliorate PTSD symptoms. The core components of PE are education about PTSD symptoms and common reactions to trauma, breathing retraining, in vivo exposure, and imaginal exposure. As always in behavioral programs, homework practice of these skills is an essential part of the treatment. Treatment begins in session 1 with a discussion of the effect of traumatic experiences and the development of PTSD, and the therapist explains the rationale underlying exposure therapy. It is stressed that posttrauma difficulties are primarily maintained by two factors: 1. Avoidance of thinking about the trauma and avoidance of trauma reminders, although effective in the short term at reducing or blocking anxiety, have prevented the event from being emotionally processed and integrated. 2. The presence of unhelpful and often erroneous beliefs and thoughts is brought about by the trauma (e.g., especially prominent are the beliefs that the world is extremely dangerous and that the trauma victim himself or herself is extremely incompetent). A clinical interview is also conducted in session 1 to acquire extensive information about trauma history and how the patient views his or her PTSD symptoms. The slow-breathing skill is taught at the end of the first treatment session and is thereafter assigned each week for homework. Daily practice is strongly encouraged. Session 2 begins with an in-depth discussion of common reactions to trauma, followed by the introduction of in vivo exposure and the construction of an in vivo hierarchy. Items on the hierarchy are ranked on the basis of the patient’s expectation of the amount of distress he or she would experience if confronting the situations. Once

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in vivo exposure is introduced, the patient chooses in vivo assignments for homework between sessions each week. The patient is instructed to remain in each situation for 45–60 minutes or until his or her anxiety decreases considerably (by at least 50%). Imaginal exposure is the last procedure to be introduced. It begins in session 3 and is conducted in each treatment session thereafter. Imaginal homework consisting of daily listening to audiotapes of the imaginal exposure continues the work of emotionally processing the traumatic experience. Sessions 4–10 follow a standard agenda. Each session begins with a detailed review of the preceding week’s in vivo and imaginal homework. Patterns of habituation are discussed, and decisions are made about where to focus exposures next. Imaginal exposure is then conducted for about 30–45 minutes, followed by a period of postexposure “processing,” during which the therapist and patient discuss the patient’s reaction to the reliving and any insights or feelings that have emerged from it. The next week’s homework is assigned. In the tenth and final treatment session, the therapist and patient review progress and what the patient has learned from using the therapy. In most successful outcomes, the patient has adopted a whole new orientation in managing his or her PTSD symptoms: avoidance maintains fear, whereas confrontation with trauma memories and reminders promotes recovery and mastery. The following is a detailed case example of a woman treated with PE for rape-related chronic PTSD.

Case Example: Ms. F
Ms. F, a 35-year-old white woman, was referred to our PTSD program by a marriage counselor. Ms. F had married for the second time about 3 years prior to this and had one child, a 6-month-old daughter. She had an associate’s degree and had left her job as a paralegal to stay home with her infant. Ms. F’s trauma history consisted of multiple sexual assaults. At around age 8 years, she was fondled by a much older male cousin, and she was fondled again by an adult male stranger at age 13 years. At age 16 years, she experienced what was in her view the worst and what remained the most upsetting sexual assault. While visiting a 16-year-old male acquaintance in his house, Ms. F was sexually assaulted by this boy and two others ranging up to age 20. During the assault, Ms. F was threatened, struck in the face, smothered by hands over her mouth, and vaginally raped by two of the assailants. She disclosed this assault to no one until her early 20s and received no help or treatment at the time. Three years after the rape, at age 19 years, Ms. F was raped again and did not disclose the assault or seek help. The initial evaluation found that Ms. F had moderately severe PTSD. Her history included one episode of major depression, beginning after the

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gang rape at age 16 and lasting at least 1 year. In addition, Ms. F had struggled for many years with bulimia nervosa, which also developed shortly after the rape at age 16. No other diagnoses were given. Ms. F sought treatment for the first time at age 26, when she entered couple therapy. She described receiving “a good deal of therapy”—both individual and group—off and on for years. Much of her therapy was focused on the effect of the sexual assaults and her struggles with poor selfesteem and binge eating. Treatment history also included an inpatient stay in a 28-day eating disorders program in her early 30s. Her bulimia had been under control for about 18 months prior to our treatment. She did not use alcohol or drugs and had no history of alcohol or substance abuse or dependence. Ms. F said that her assault-related problems had waxed and waned over the 20 years since her first rape but had never been resolved. The catalyst for seeking treatment in our program was the birth of her daughter 6 months earlier. Ms. F reported that a lot of feelings and memories of her past assaults had been stirred up by the birth. She was experiencing frequent intrusive thoughts and images of the first rape, intense emotional distress when reminded of it, avoidance of thoughts and situations that triggered assault memories, nightly sleep disturbance, and chronic irritability. In addition, she was experiencing fear and worry about her daughter’s safety and future. She wanted to resolve these problems and fears “before it affects my daughter, too.” It was apparent early in treatment that Ms. F was feeling extreme shame and guilt about her assault history. She had long-standing and deeply held beliefs about being abnormal, damaged, and “bad.” She commented several times: “It’s one thing to be raped once, but something is wrong with someone who gets raped more than once.” Ms. F also had strong guilt and shame related to the belief that she had not done enough to fight off her assailants at ages 16 and 19; she reported: “I did absolutely nothing. My body just shut down, and I let them do whatever they wanted.” These feelings and thoughts were prominent in her imaginal exposure from the beginning. Imaginal exposure initially focused on the gang rape at age 16 because this was the most distressing and most frequently reexperienced trauma. After five sessions, Ms. F began processing the second rape at age 19, also using imaginal exposure. Her in vivo exposure hierarchy included items such as going to the area where she had met the boy the day she was raped (an objectively safe place), interacting with men of the same race as her assailants, interacting with unfamiliar men in church or in other settings (e.g., asking men for directions or for assistance in a store), going out after dark, and sleeping in her bed with the curtains open when her husband was away. Ms. F was highly motivated, worked hard in her therapy, and was faithful in following through with homework assignments and practicing the skills between sessions. Ms. F showed effective emotional engagement with the traumatic memories during her imaginal exposures. She reported initially high distress (subjective units of distress) levels and then showed progressive habituation of anxiety within and between subsequent sessions. Her affect

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during exposure was congruent with her self-reported distress level. Successful emotional processing of the traumatic experiences was seen in several other ways as well. Immediately after her third imaginal exposure, she spontaneously said: “I’ve been listening to myself say over and over, ‘I’m doing nothing to stop them,’ and it’s beginning to hit me.. .. What did I think I could do? I was scared to death.” She reported in the next session that for the first time, she felt “at peace” with herself about her behavior during the rape. This acceptance was enhanced by her recall of a few parts of the assault that she had not really thought much about before. For example, her distress about “not doing anything” to resist her assailants also was diminished when she recalled that early in the assault, one of them had put his fist to her face, threatening to “let her have it” and terrifying her into submission. After the imaginal exposure in the following session, she spontaneously said: “You know, I’m beginning to realize that all these years I’ve blamed myself for the rape, but it’s really not about me, it’s about them. They raped me.” This was quite a significant shift in her view of the assault and her culpability for it. The treatment produced a significant reduction in Ms. F’s PTSD symptoms and in her depression and anxiety. Assessments were conducted before, immediately after, and up to a year following therapy. Ms. F’s PTSD severity decreased by 70% from pre- to posttreatment, and 12 months after treatment ended, the severity had declined by 90% from the pretreatment level. Comparable decreases in depression and anxiety were observed. Ms. F continued to maintain her treatment gains. She spontaneously called her therapist 2½ years after treatment ended to report that she had recently run into one of the men who had raped her so many years ago. He engaged her in a conversation, which she allowed, and in the course of it, he acknowledged that he had “treated her very badly” when they were younger. Ms. F agreed that he had and calmly accepted his apology. As she related this story to the therapist, she said that what pleased her the most about this conversation was that “it just didn’t matter to me. .. I don’t care that he apologized, I didn’t need it, and it doesn’t change how I feel OK today about the past.” She felt that this was final proof of how thoroughly the therapy had helped her to resolve the traumatic experiences of her past.

Summary
Behavior therapy is an extensively validated and effective treatment for a variety of disorders, including anxiety, posttraumatic stress, depressive, impulse-control, and personality disorders, as well as for marital and family problems. It pays little attention to gaining insight into the origins of the problems, because insight does not necessarily lead to change. It seeks instead to make changes in current behavior and to maintain these in the future. Therapy is time limited, collaborative, and focused on the pres-

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ent. A thorough initial assessment, which is critical, leads to a treatment plan and psychoeducation regarding the problem and the rationale for behavior therapy. Therapy then becomes very active—active behavioral techniques such as relaxation, exposure, problem solving, and role-playing are used in sessions and practiced after sessions as regularly prescribed homework. The approaches presented here—SIT and two specific forms of exposure therapy, EX/RP for OCD and PE therapy for PTSD—are best learned under supervision and should allow therapists to successfully treat many of the patients seen in a brief therapy practice.

References
Antony MM, Swinson RP: Phobic Disorders and Panic in Adults: A Guide to Assessment and Treatment. Washington, DC, American Psychological Association, 2000 Antony MM, Orsillo SM, Roemer L (eds): Practitioner’s Guide to Empirically Based Measures of Anxiety. New York, Kluwer Academic/Plenum, 2001 Brown TA, DiNardo PA, Barlow DH: Anxiety Disorders Interview Schedule for DSM-IV, Lifetime Version. San Antonio, TX, Psychological Corporation, 1994 Clark DM: A cognitive model of panic attacks, in Panic: Psychological Perspectives. Edited by Rachman S, Maser JD. Hillsdale, NJ, Lawrence Erlbaum, 1988, pp 71–89 De Araujo LA, Ito LM, Marks IM: Early compliance and other factors predicting outcome of exposure for obsessive-compulsive disorder. Br J Psychiatry 169:747–752, 1996 First MB, Spitzer RL, Gibbon M, et al: Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician Version (SCID-CV). Washington, DC, American Psychiatric Association, 1997 Foa EB, Kozak MJ: Emotional processing of fear: exposure to corrective information. Psychol Bull 99:20–35, 1986 Foa EB, Riggs DS, Dancu CV, et al: Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. J Trauma Stress 6:459–473, 1993 Goodman WK, Price LH, Rasmussen SA, et al: The Yale-Brown Obsessive Compulsive Scale (Y-BOCS): past development, use, and reliability. Arch Gen Psychiatry 46:1006–1016, 1989 Kozak MJ, Foa EB: Mastery of Obsessive-Compulsive Disorder: A CognitiveBehavioral Approach. San Antonio, TX, Psychological Corporation, 1997 Leung AW, Heimberg RG: Homework compliance, perceptions of control, and outcome of cognitive-behavioral treatment of social phobia. Behav Res Ther 34:423–432, 1996 Mavissakalian MR, Prien RF (eds): Long-Term Treatments of Anxiety Disorders. Washington, DC, American Psychiatric Press, 1996 Meichenbaum D: Stress Inoculation Training. New York, Pergamon, 1984

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Rachman S: Emotional processing. Behav Res Ther 18:51–60, 1980 Riggs DS, Foa EB: Obsessive-compulsive disorder, in Clinical Handbook of Psychological Disorders: A Step-by-Step Treatment Manual, 2nd Edition. Edited by Barlow DH. New York, Guilford, 1993, pp 189–239 Veronen LJ, Kilpatrick DG: Stress management for rape victims, in Stress Reduction and Prevention. Edited by Meichenbaum D, Jaremko ME. New York, Plenum, 1983, pp 341–374

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piercing the veil of objectivity. graduate students in counseling. of course. so I might as well allow yellow brick readers a full view. this would constitute unspeakable rudeness. To do so would be like pulling the curtain from the Wizard. graduate. I have already spoiled any possibility of your ignoring the man behind the curtain. hardly dare write from the first-person perspective. Ph.D. My students refer to me simply as Brett. I teach in an academic health center. and psychiatry residents. With this introduction. Have you ever noticed how authors of journal articles and book chapters rarely introduce themselves at the start of their writing? In a social context. however. and health professional stu85 . where I supervise psychology interns. Steenbarger.4 Solution-Focused Brief Therapy Doing What Works Brett N. Scholars. nursing. I also direct a program of counseling for medical.

I assume that you have acquired this book in order to assist yourself in developing your skills as a brief therapist. are the vessel waiting to be filled by me. you probably helped shift that person’s perspective. you probably come to this text with several assumptions. let us turn these assumptions on their head and see what happens. Try to put yourself in the other person’s shoes and form an image of what he or she would have experienced in his or her interaction with you. you are in the role of absorbing these. the reader. in tone or words. providing him or her with a novel way of viewing the situation and perhaps some new ways of responding to the challenge. I am in the active role of delivering ideas and skills. Quite likely. In any event. I want you to vividly replay that helping episode in your mind. if your child was experiencing conflict. If there is a singular passion in my professional life. of course. If your friend came to you with a loss. The odds are good that you began your helping by attentively listening to the other person. making it clear that all was not hopeless. does it? So. it is the issue of change: understanding how people change and how we can become ever more effective and efficient as change agents. Please recall a recent occasion in which you helped a person make a change in his or her life. while we are getting acquainted. Regardless of the details. focusing on what you did and said to help the other person make the change. the expert. entails yet another assumption: that you have certain holes in your training and experience that need to be filled. I strongly suspect that there will be some universal elements. Now. This. Notice how these very natural and basic assumptions structure our relationship. Perhaps you are a graduate student or resident learning short-term approaches to therapy for the first time. you may have modeled a strategy for resolution. Alternatively. You also assume that I will attempt to share this background with you in the chapter and that you will be able to absorb some of these ideas and apply them to your practice. It could be as simple as assisting a friend through a loss or helping your child with a conflict at school. you might be an experienced counselor or therapist looking to hone your talents and add to your repertoire. That does not sound like a very promising start to our fledgling relationship. the way you sat or stood beside the person—as well as your specific messages. you expressed a degree of encouragement.86 The Art and Science of Brief Psychotherapies dents. as a chapter author. you are . your tone of voice. you might have helped him or her see that all was not lost. You. have certain experience and expertise in the field of solution-focused brief therapy. and it does not even have to be a therapeutic change. expressing concern and interest. however. Although the details of your scenario will be unique. It does not have to be an earth-shattering change. You assume that I. Perhaps most important of all. Imagine the nonverbal elements—your look.

Instead. My goal in this chapter is not to enable you to conduct brief therapy in the manner of recognized practitioners. and then do those things more consistently and intentionally. Instead. SFBT emphasizes goals and ways in which clients are already (if inconsistently and incompletely) achieving these. As a reader. Instead of focusing on what people lack. strategic. then you already know quite a bit about how to do brief therapy. Any Pygmalion-inspired hope I may have harbored . you. it was my parenting experiences that first interested me in SFBT. if you can catalog enough examples of your successful helping in personal and professional settings. Essence of Solution-Focused Brief Therapy By now. If you were able to achieve these ends with another person in the course of a single helping interaction. experience. solutionfocused. and/or skill. you probably will find that you know more about short-term work than you think because you will have a template for the kinds of brief helping that you do best. You acquired this book to fill the holes in your training. Moreover. SFBT. Interestingly. stands the usual assumptions of therapy on their head. like the earlier paragraphs. effective facilitator of change. I can imagine that a mouse that saw only holes would never find Swiss cheese. cognitive. I wish you to consider becoming more of the effective helper that you already are when you are at your best. I quickly learned that they came into this world with temperaments and behavior patterns far different from my own.Solution-Focused Brief Therapy 87 likely to have accomplished three things in your helping: 1) the establishment of a trusting bond. or interpersonal. you have probably figured out my game. 2) the introduction of hope and optimism. and 3) the creation of a novel perspective. Similarly. feel. it looks for occasions in which they are able to think. whether it is behavioral. Analyzing the past and developing insight into conflicts are thus not a part of SFBT. Because that is what brief work is all about. and act in ways that move them toward their goals. nor are behavioral analyses or the keeping of problem-based journals. Identify what you are already doing when you are an efficient. and so your perspective is hole centered. clients who are locked into their problems frequently are starved for solutions. The introductory paragraphs were my solution-focused brief therapy (SFBT) with you. psychodynamic. As the father of two adopted children. like most clients. might come to this text focused on your problems and deficits. I also do not intend to encourage you to do therapy my way.

and directed tasks to alter problem patterns. My job is to learn as much as I can about my clients and find out how they are already doing some of the things that they want to be doing in their lives. which emphasize the self-reinforcing nature of problems and attempted solutions. Assumptions of Solution-Focused Brief Therapy The underpinnings of SFBT can be traced to the pioneering work of the Bateson research group on schizophrenia in the 1950s. I recognized this same attitude. only heighten the sleeplessness because the process of trying to fall asleep interferes with the necessary relaxed state of mind. sleepiness can emerge naturally. that is wonderful. such as when they are engaging in routine. become increasingly concerned with their problem. boring tasks. but my role is not to mold others to my preconceived image. A SFBT practitioner. I realized that if I were going to be at all successful as a father. change simply requires an interruption and shift of these attempts at solution. seek minimal interventions to break these vicious cycles. Erickson. Instead of analyzing and working through these problems. given their personalities. metaphoric communication. Jay Haley—were familiar with the innovative brief therapy practice of Milton H. for instance. I would have to learn who these little people were and then help them become the best individuals they could be. which examined the role of communication processes in emotional disorders. skills. for example. Clients with insomnia. In this way.88 The Art and Science of Brief Psychotherapies about creating them in my image was dashed at the outset. Each individual comes to therapy with his or her own tools. If I can be a model for my clients. Instead of trying to fall asleep. . and exceptions to these problems. inspired strategic and single-session therapies. followed by the efforts of Richard Bandler and John Grinder and of Steven Lankton. Then I have an opportunity to help them become more of who they already are. Many of the group members—most notably. Haley’s efforts to understand Erickson’s work. problems. and interests. might have clients with insomnia explore what is happening at those times when they are able to feel a little bit drowsy. These efforts. without the interference of effort and frustration. Strategic therapists emphasized that people are suffering not so much from their problems as from the ways in which their attempted solutions maintain these problems. trying everything possible to fall asleep. who used hypnosis. When I first encountered SFBT. the client is encouraged to forget about sleeping and perform some of the routine tasks that have been associated with drowsiness in the past. These approaches. however.

often reinforcing the very concern that they are trying to address. and interpersonal conflicts are seen as things that people do. and beliefs. to develop an approach to therapy that was explicitly solution focused. they engage in various behaviors to address this problem. making it one of the most popular brief approaches to therapy. Once people construct the notion that they have insomnia. de Shazer (1985. generally in fewer than 10 sessions. according to the SFBT practitioner. once identified. SFBT draws heavily on constructivism: the notion that the problems experienced by clients are not intrinsic to them but the result of the ways in which they construe themselves and their world. Maintaining a problem focus in therapy by exploring and targeting unwanted patterns only reinforces the mode of construal that troubles the client in the first place. Such solutions. p.Solution-Focused Brief Therapy 89 The strategic focus led de Shazer and colleagues at the Brief Family Therapy Center in Milwaukee. 11) stressed. Once . Wisconsin. de Shazer instituted a variety of strategies for inquiring about and reinforcing examples of solution: those instances in which clients behaved in ways consistent with their desired ends. social. can anchor new adaptive efforts. Instead of exploring the initial complaints of clients and maintaining a problem focus. A problem. interpretive processes mediated by people’s experience. is not so much the pattern of behavior that brings the client to therapy but the construal that reifies this pattern as a problem. anger. Constructivism is a philosophical tradition that emphasizes perception as the result of active. anxiety. diminished self-esteem. Subsequent writings by O’Hanlon and Weiner-Davis (1989) and Walter and Peller (1992) have elaborated on the SFBT model. By circumventing traditional procedures of evaluating and exploring past problems. solution-focused therapy was able to address the concerns of clients in a brief fashion. not as things that they have. and active. SFBT seeks to construct alternatives to problem-based construals. The crucial assumption made by SFBT is that therapy is more of an epistemological activity than a medical or therapeutic one. Common complaints such as depression.” Walter and Peller (1996. desired patterns as objectives. as clients are encouraged to do more of what might work for them. only becomes a problem when it is so construed by an individual. In a series of efforts to map the structure of therapy. “We live in a world of meaning and language that is creational. such as the insomnia mentioned earlier. From a theoretical vantage point. 1988) identified exceptions to presenting problems as fundamental to this solution-focused approach. values. and by targeting specific. The real problem. These can be identified from implicit goals brought to therapy by clients and from exceptions to problem patterns that are similarly implicit. Accordingly.

anxiety. SFBT is less about solutions than about goals and possibilities. have the capacity to envision change. from situational stress to a severe cold. It is the person’s identification with the problem. This latter point is especially important. Walter and Peller (1996) used the term goaling to describe the ways in which individuals continually develop life possibilities. and are doing their best to make change happen. A couple may be so mired in arguing that they cannot think of a single recent time in which they have interacted positively. The client enters therapy with problems in the foreground of perception. is probably already happening” (p. Much of the “stuckness” that we observe in therapy—and in our own personal lives—can be seen as the result of “probleming” overtaking “goaling. Further. Still. The SFBT practitioner is thus more concerned with the factors that maintain problems than with initial causes. Even when distinct exceptions to problem patterns cannot be identified. the individual gains the ability to do something different and discover new. An appealing aspect of SFBT is its emphasis on client strengths and assets. they might be able to identify elements of such positive interaction from their days of dating.” The emphasis on problems blocks the creative search for alternatives. despite its name.’” Once this identification is broken. de Shazer (1988. Indeed. SFBT attempts to shift this focus to the life that clients want to be living. in their review. it is a candidate for a constructed solution. 478). jointly guided by the participants. from this perspective. Solutions are not therapist-driven framings of problem patterns. constructive patterns that become solutions.90 The Art and Science of Brief Psychotherapies the person diagnoses himself or herself as someone “with” depression. solution-focused therapists assume that the solution. however. . or their communications with members of their extended families. they are grounded in the adaptive efforts of clients already under way. is less of an end point than a process of evolving meaning. Rather. Gingerich and Eisengart (2000). it is usually possible to encourage people to imagine what such an alternative might look like. Problems are held together simply by their being described as ‘problems. Once this can be identified. their professional interactions. p. The objective of therapy. or at least part of it. Simon (1996) and O’Hanlon and Weiner-Davis (1989) made the important point that. or interpersonal problems. that is necessary for its maintenance. The operative assumption is that somewhere there is a context in which clients do not enact their problems. 8) observed that “problems are problems because they are maintained. this identification cements the status of the problem. stifling healthy development. and it places this in the foreground. noted that “solution-focused therapists assume clients want to change. a problem such as insomnia may be initiated by any of a variety of factors.

G voiced her greatest concern that the two of them would wind up like her parents: a couple who lived together but showed little mutual affection. Both affirmed that they wished the marriage to continue and expressed a desire to avoid divorce at all costs. I’m just not hearing much about the love in your marriage. and Mrs. and Mrs. H. lamenting how they had “grown apart” during their rigorous years of school. and Mrs. “I’m not sure I can help you. Mr. G emphatically stated that they did love each other and spontaneously produced several examples of their dedication to each other. she could not see how it would be possible to make things right. and Mrs. H but also indicated that he appreciated her honesty after the fact. G. G. G’s relationship with Mr. Mr. “although I would like to. and Mrs. given the demands of their education. G began spending more time with Mr. in which both members of the couple participated actively. G said that she had enjoyed this time in medical school most of all because of their feeling of being “a team. both medical students. Mr. I attempted to use Mr.” I explained to them. such as paying bills and doing grocery shopping. Mrs. go out. G became ill and Mr. G. leading them to feel more like roommates than romantic partners. found that their studies caused them to spend decreasing time with each other. a couple who sought counseling for marital problems. G’s motivation as a lever in the search for solutions. or make love. were taken up with the routine tasks of maintaining a home. G made a heroic effort to nurse her to health. and Mrs. Matters came to a head when Mrs. G’s parents or the detailed history of their own relationship. One such example centered on an episode in which Mrs. Counseling can certainly help a couple work out difficulties between them. Their days. The preceding information came from the first interview.” At this.” Another instance of love . and during one latenight study session. a study partner from her class. she kissed him. H. They reported being too tired at night to talk. G expressed more resignation than Mr. Although she did not want to leave the marriage. G A good example of the ways in which SFBT intervenes in the meaningmaking of clients can be found in my counseling with Mr. Mrs. Although she had been quite ill. Both agreed to seek marital counseling that week. Rather than explore the relationships of Mr. but it can’t replace love that isn’t there. who became both angry and concerned for the marriage. G acknowledged his anger over Mrs. Mrs. while helping her keep up with her course work. G. Mrs. She guiltily confessed her transgression to Mr. G began feeling an attraction to Mr.Solution-Focused Brief Therapy 91 Case Example: Mr. when not filled with classes and study.

Each of them was willing to accept a lower grade for himself or herself to help the other one pass. We held a total of four sessions. and they provided many ideas. lessening any lingering concerns Mr. Mr. the other usually was very willing to put down his or her work and offer a hug. they committed to spending one night together per week and 1 hour together per day in a mode that was free of schoolwork and home tasks. homework. G for study sessions at a local college library. G to give themselves a report card grade on their marriage. Both could agree that they were willing to accept possible lower scores on their medical school tests to help each other pass the elective course we had established. including taking day trips to area parks. We spoke of Mr. where they took study breaks together. These focused on their efforts at teamwork and togetherness and grading each other’s work. The example of Mr. and Mrs. ranging from A to F. I then introduced a modified version of the scaling question and asked Mr. When one of them became fatigued or discouraged. G’s reaction of jealousy and concerns re- . Nor did we dwell on the events that drove the couple apart or that led to the attraction to Mr. G described the ways in which they would study together before examinations. and Mrs. both were able to give each other an “honors” mark for their progress. and signing up for a several-session weekend adult education course on techniques of massage. and some encouragement. We did not explore family histories of dysfunction or their own personal relationship histories. a kiss. I suggested to them that they make their couples counseling a medical school elective. G had about Mr. H and instead joined Mr. I asked what would have to happen between the two of them for a grade of “honors” to be earned. This convinced them that the best way to be at their peak for their studies was to be happy with their marital life. G reported greater emotional and physical intimacy as a result of their time together. scheduled intermittently. H. H. Both members of the couple warmed to this idea and indicated that they wanted an “honors” grade for “our” course. By the end of the fourth session. G discontinued her studying with Mr. When they both rated their marriage as a “D” and asserted that they would never settle for such a grade in school. Most concretely. even after spending considerable time together in a nonwork mode. staying overnight at a bed-and-breakfast inn. Mrs. A particular breakthrough occurred when both of them raised their scores on examinations. mostly building on the idea of teamwork and togetherness. and a grade at the end. It also spawned a variety of creative strategies for enjoying their time together. G is as notable for what was not undertaken as for its affirmative strategies. complete with expectations of attendance.92 The Art and Science of Brief Psychotherapies surfaced when Mr. and Mrs.

positive therapeutic alliance Efforts to facilitate change in a time-effective manner Therapist activity Efforts to involve clients in change efforts through within-session experiences and between-session homework • Relative de-emphasis on the past and emphasis on generating novel experiences. were still in love and doing loving things while not even noticing it. understandings. based on the individual’s stated goals. Rather. People are seen as continually changing and capable of change. Chapter 1. SFBT falls on the briefest end of this continuum. including • • • • • Maintenance of a tightly circumscribed focus Efforts to establish an early. in this volume). our focus was on helping them do more of what they already had been doing to sustain the marriage. while feeling estranged. The major brief therapies share several elements (Steenbarger 1992).. Once they have established a useful direction and an appreciation for what they are already doing that is . It took a subtle threat—the statement of “I don’t know if I can help you”— to galvanize the couple into an acknowledgment of the assets they already possessed. the focus was on the love between them and how this was manifested. A tight focus for intervention is generally established in the first session. from the outset.Solution-Focused Brief Therapy 93 garding trust. Rather. Reviews of SFBT generally have found an average number of sessions ranging between three and five (McKeel 1996). The assumption was that the couple. but not as central themes in the sessions. and skills The various approaches to brief therapy embody these elements differently and thus differ in their use of time (see Steenbarger et al. There was essentially no teaching of skills in the sessions. Compressed Duration of Solution-Focused Brief Therapy Let us step back a moment and examine the characteristics of SFBT that qualify it as a brief therapy. eliminating much of the time associated with problem talk and diagnosis. • SFBT views its objective as initiating change rather than seeing clients through an entire change process. Such brevity is attributable to several factors: • SFBT establishes its solution focus early.

to be sure. in-session exercises. Some may view SFBT as “solution-forced” counseling. • SFBT stresses client definitions of goals and. The real change occurs. in the context of this enhanced experiencing. the client begins to internalize a new sense of self: one that emphasizes competence and the capacity for control. the techniques of brief therapy bring individuals closer to the anxieties. and homework tasks. Research conducted to date and outlined later in this chapter suggests that SFBT is effective. and/or new experiences of oneself. new skills for coping. helping to structure the solution talk. however. Then. places little time and emphasis on resistances and work to overcome these. These are real pitfalls. These individuals are apt to be dissatisfied with any brief modality.to five-session therapy for clients with chronic problems such as major depressive disorder. with direct suggestions of “doing something different” if current strategies are not working and doing more of what works. and losses that trouble them.94 The Art and Science of Brief Psychotherapies bringing them closer to their goals. Through the use of active interpretations. immediate confirmation of their adaptive capacities. when clients actually begin doing more of what works and see that it really does work. resentments. . SFBT or otherwise. SFBT achieves this novelty through its redefinition of presenting complaints. Just as experiences during periods of trauma tend to imprint themselves on the psyche. raising questions about the appropriateness of three. With support and encouragement—a bit of cheerleading—from the therapist. but relatively little work has been done with long-term follow-up to determine rates of relapse. Also. concerned that clients’ normal need to talk about their concerns could be truncated by therapists hell-bent on brevity and solution-talk. • The SFBT therapist is active from the outset. the novel experiences of brief therapy tend to “stick” in emotionally charged circumstances. Elsewhere (Steenbarger 1994). Highly abbreviated therapies may have a better track record initiating change than sustaining it (Steenbarger 1994). hence. they can sustain change efforts independently. brief therapists introduce new ways of viewing problems. I have proposed that brief therapy achieves much of its brevity by generating novel experiences under conditions of heightened emotional experiencing. Clients come into therapy seeking help for their problems and leave with a focus on their assets and solutions. many clients enter therapy not only for reasons of self-change but also for ongoing social support. The brevity of SFBT raises concerns that perhaps the work is too brief. This is a direct. SFBT also emphasizes client activity between sessions.

comes from recognizing that there was no real problem. moderately controlled. As a result. Attempts to objectively assess and measure such changes need not collide with a therapist’s commitment to explore and expand existing adaptive efforts. Is it necessary to abandon the DSM framework and outcome assessment in order to practice SFBT? As Held (1996) argued. clients do make real changes in their lives as a result of SFBT. they do not establish that SFBT is uniquely effective relative to other brief forms of therapy. Thus. and antisocial adolescent behavior. The constructivist bent of SFBT questions the notion that people enter therapy with objective. the authors located 15 controlled outcome studies of SFBT. If the improvement shown by therapy clients significantly exceeds that of persons receiving a placebo intervention. we are now seeing studies not only of SFBT outcomes but also of the component processes that may be contributing to success in SFBT. 493). parenting skills.Solution-Focused Brief Therapy 95 Effectiveness of Solution-Focused Brief Therapy A small but growing literature documents SFBT as an effective therapy. although “these five studies provide initial support for the efficacy of SFBT” (Gingerich and Eisengart 2000. diagnosable problems and illnesses. McKeel (1996) noted that some of these outcome studies did compare the effects of SFBT with those of existing services within school and prison settings. which then can be followed up over time to assess objective improvement. or no help whatsoever. and this found no significant difference between the two. 5 of which met the criteria for well-controlled research. an alternative therapy. Only 1 of the 5 directly compared SFBT with another therapeutic approach. p. McKeel (1996) also summarized process-oriented studies of SFBT. and poorly controlled. Change. Many practitioners of SFBT rebel against such outcome assessment because of its grounding in epistemological realism. Through 1999. In his review. rehabilitation of orthopedic patients. Outcome studies generally presume that clients come to therapy with real problems. These 5 studies supported the efficacy of SFBT for problems such as moderate depression. Gingerich and Eisengart (2000) offered a particularly useful review of the SFBT outcome research. dividing studies into three categories: well controlled. the therapy can be said to have been effective. recidivism of prisoners. examining the effectiveness of typical . they insist. establishing the effectiveness of SFBT above and beyond the existing services. that clients were already doing what they needed to be doing to become unstuck from their patterns.

yielded further noncontrol. Beyebach et al. Wisconsin. providing instructions. Clients completing the formula first session task also were significantly more likely to report improvement and optimism than were those not performing the task. at this follow-up period.” These outcomes did not appear to vary as a function of client race or the gender mix of the therapeutic dyads.” the authors . “These results show that locus of control is variable and becomes more internal over the course of successful therapy. Interestingly. was found to enhance client cooperation.” noncontrolling communications. which reflects the degree to which individuals perceive that they are in control of their lives. Their investigations highlighted the role of communications between therapists and clients as an ingredient of success. Moreover. and found that approximately 80% of the clients reported satisfaction with their therapy 7–9 months after their counseling. and another 37% indicated that they had made “some progress. in the successful cases. therapists tended to be more directive. The formula first session task. whereas an excessive amount of agreement between therapists and clients led to increased relapse. “One-across. conversely. This suggests that a focus on positive change can be viable for most clients. which encourages clients to focus between sessions on what is happening in their lives that they would like to continue. suggesting that a high level of satisfaction with services—and significant perceived success—can be achieved and sustained in a time-effective manner. Dyads that showed a competitive battle for control of session topics obtained less favorable outcomes than did those without such control struggles. 49% of the clients reported that their therapy goals were fully met. (1996) examined SFBT outcomes and found that the sole significant predictor of success was client internal locus of control. These changes are significantly more likely to emerge in therapy if targeted by the therapist in the first session. Sequential analyses found that controlling “one-up” and “one-down” communications in therapy tended to elicit subsequent controlling communications from the other party. DeJong and Hopwood (1996) summarized outcome research at the Brief Therapy Family Center in Milwaukee. McKeel (1996) also cited evidence that most clients do report pretreatment changes— improvements that have occurred between the time of calling for an appointment and attending that appointment. if therapists think to ask the questions. A series of studies reported by Beyebach and colleagues (1996) examined the processes contributing to success in SFBT. Interestingly.96 The Art and Science of Brief Psychotherapies SFBT interventions such as the formula first session task. the clients received an average of only three sessions of therapy. The internal locus was positively correlated with favorable pretreatment reports of change and subsequent goal formation in counseling.

the nature of client–counselor communications and the ability to support and extend reports of pretherapeutic change may be every bit as important as the specific tasks initiated by therapists. SFBT may be more successful when it involves complementary control than when it involves noncontrol. both parties can feel appreciated and in the driver’s seat. Specifically. The manner in which I presented the studies undoubtedly made my own biases known. such as systematic desensitization. which are that SFBT is an effective and innovative therapy that probably works for reasons other than those typically postulated. who found that clients and therapists in SFBT view the events of therapy quite differently. are generally appreciative of the role of persuasion and interpersonal influence in change processes. Practice of Solution-Focused Brief Therapy By now. directive therapies. The directive in- . This conclusion finds support in the qualitative research reported by Metcalf et al. more directly connected to the work of Erickson. O’Hanlon. are easier to manualize than are more exploratory therapies. Practitioners may be confusing the process of guiding therapy (which therapists direct toward solutions from the outset) with the content of counseling goals (which rightly come from the client). you have some idea of what SFBT is. 1996. Such an analysis suggests that SFBT may work for reasons other than those postulated in the theory. (1996). Given that nonspecific factors tend to be of importance across psychotherapies (see Greenberg. and where it stands relative to issues of brevity and efficacy. In the terms of Beyebach et al. Chapter 8.Solution-Focused Brief Therapy 97 noted. 325). such findings are not surprising. therapists tended to see themselves as relatively nondirective. whereas clients emphasized the role of the helping relationship. In particular. on reviewing transcripts of his SFBT sessions with clients. When clients have control over goal specifics and counselors exercise control over the process of focusing on and attaining goals. “This lends support to the notion that the task of solution-focused therapists is to foster situations in which clients experience a better sense of control over their own lives” (Beyebach et al. Therapists also were likely to attribute success to goal-oriented interventions in therapy. whereas clients pointed to direction as a central helping element. (1996). in this volume). how it fits into the larger scheme of brief therapy. As a rule. Strategic therapists. In general. p. I find the notion that solution-focused therapists are nondirective to be well wide of the mark. was said to have been surprised by the degree to which he spoke for clients (McKeel 1996).

In their review. Gingerich and Eisengart (2000) described seven distinctive criteria for SFBT: 1. 4. What was essential was a goal and an idea of how to achieve that goal. The natural ebb and flow of problems suggests that these might abate to some degree after the initial call. Certain specific techniques distinguish SFBT as a modality. de Shazer was interested in capturing the process by which people change in therapy and distilling this process to its essence. given the concerns of the client at the time. It is much easier to describe how to do relaxation training than how to turn a countertransference reaction—a therapist’s reaction to a client—into an effective intervention.98 The Art and Science of Brief Psychotherapies terventions are largely technique driven and often depend on using the techniques in a particular sequence. having failed in their prior attempts to solve their problems. the therapist might encourage the client to be on the lookout for changes that occur during the time between the telephone call and the first meeting. Search for Presession Change We are accustomed to beginning therapy with the first session. once the client has entered the office. During that call. 7. de Shazer’s maps describe procedures for eliciting goals and either existing or hypothetical ways by which clients can pursue these. thanks to the interests of its founder. Steve de Shazer. by their very nature. The solution-focused therapist. As a result. A search for presession change Goal setting Use of the miracle question Use of scaling questions A search for exceptions A consulting break A message including compliments and a task These seven criteria constitute the SFBT road map of change. Exploratory therapies. Walter and Peller 1992). can be described relatively straightforwardly and even mapped out (de Shazer 1988. The practice of SFBT. He found that problems and their discussion were not essential to change. Most clients call for their initial session when they are at their point of maximum discouragement. 5. Let us examine each in turn and then explore the map as a whole. 6. This subtly makes use of regression to the mean as a therapeutic tool. can go in any of a number of directions. 2. however. 3. . may view the initial call for an appointment as the actual start of SFBT.

Solution-Focused Brief Therapy 99 if only as a return to a normal baseline.” Such statements. this is why they seek help from a professional. The language in which the discussion of presession change proceeds is important: it frames such change as something the client is doing rather than as something happening to the client. say little about what clients affirmatively want for themselves. Such variation becomes an opportunity for inquiring about what the client is doing differently when the problems abate.” then the therapist might reply by asking. If the client says. although a start in establishing a direction for therapy. as a result. “I would like to do well in my classes. By pointing to those occasions when the individual is doing something that produces desired change. Goals do not emerge from analyses by the therapist. which are then interpreted to clients or otherwise recommended to them via a treatment plan. Questions about presession change establish the solution focus very early in therapy and quickly engage the client in the active process of thinking about solutions between sessions. the therapist highlights the control that clients may have but may not recognize. aiding the construction of potential solutions. is not only solution talk but also a greater sense of internal locus of control. Anchoring therapy in client goals minimizes the likelihood of resistance by ensuring that the participants in counseling are working toward common ends. • Goals are stated in positive form—Many times clients describe their goals in negative terms. such as “I would like to feel less depressed. therapists might follow up with questions such as “What do you see yourself doing when you’re not depressed?” or “What will be different in your life if you’re not depressed?” A positively stated goal might then emerge. such as “I will reach out to others when I feel depressed. Goal Setting Walter and Peller (1992) indicated that goal setting occurs very early in SFBT and is distinguished by several characteristics: • Goals come from the client—Goals are stated in the language of the client and reflect the desired ends of the clients. What is being constructed.” • Goals are stated in active form—The goals of therapy should be stated in the active terms of what the client would like to be doing rather than as some future end state. “What do you see yourself doing differently when you are doing better in your classes?” The active framing of goals helps to translate them into con- . As a result. Clients often feel out of control with respect to their problems.

for there is no obvious bridge between his or her current state of affairs and his or her stated ideal. might be “I will take care of myself by exercising each day. Walter and Peller (1992) noted.100 The Art and Science of Brief Psychotherapies crete tasks for therapy. clients in a high state of readiness for change (Prochaska and DiClemente 1986) may find the active goal orientation of SFBT more helpful than those who are in early phases. only just beginning to contemplate the commitment to change. specifically. “What might you be doing right now if you were on track toward developing a successful relationship?” The idea of being “on track.” • Goals are stated in specific.” This leaves the client stymied. Many times. A useful exercise in therapy is simply to ask the client to restate the goals of the therapy. emphasizes the process of change. attainable terms—It is not unusual for clients to state that they would like greater self-esteem or to feel better about themselves. This. Such a goal might be framed as “I will put myself into two situations this week in which I have to introduce myself socially. This was described by de Shazer (1988. the therapist is apt to solicit a reframing of the goal statement by asking. By asking a question such as “What.” • Goals are stated in here-and-now terms—Many times a client goal might be stated as a future state of affairs.” More than 15 years of having supervised psychology interns and psychiatry residents in brief therapy has convinced me that such work generally runs aground when goals are insufficiently salient to clients and therapists. Use of the Miracle Question One of the most common ways of eliciting goals in SFBT is through the miracle question. would you be doing right now if you were developing better feelings about yourself?” the therapist facilitates a crucial translation to goals that empower the client and foster the sense of internal control.” described by Walter and Peller (1992). a vague and even confused response is elicited—and many times a different response from the therapist! Perhaps only behavior therapy rivals SFBT in the degree to which the goals of therapy are defined in highly explicit terms and then pursued in a systematic manner. p. Accordingly. Such a self-esteem goal. stated specifically. leaves them in little control of goal attainment because they cannot change their feelings about themselves through a mere act of will. 5) as fol- . When this occurs. creating a present-day bridge between real and ideal. such as “I would like to be in a successful relationship. A goal stated in active form could then be “I will break my work into manageable chunks before I study.

de Shazer (1988) noted. “A 5 rating? That is better than many couples starting counseling. This could easily lead to solutions that allow for meeting people in ways that do not involve the spending of money. The question “How would your best friends (e. interpersonal behaviors that can become initial goals for therapy. with an average of 5. there was a miracle and this problem was solved. Use of Scaling Questions A scaling question in SFBT. is a request for client self-report. It also can be an effective tool in eliciting client goals.Solution-Focused Brief Therapy 101 lows: “Suppose that one night. as in behavioral work. concrete terms. “Through the use of the miracle question. By asking about the “average” rating.g. Such . confused. the therapist can then naturally inquire about those occasions that are above average and what makes these different. family. How would you know? What would be different? How would your husband know without your saying a word to him about it?” The miracle question. spouse) know that you had solved this problem?” also is helpful in encouraging clients to frame goals in observable.” on average. or otherwise poorly described” (p. The framing of the question as a “miracle” allows the client to step outside current constraints that might be inhibiting the search for solutions. follow-up questions might be “So. For example. Such a question might be “On a scale from 1 to 10.” de Shazer noted. The miracle question allows the client to look beyond the lack of funds and define what would be happening if he or she were on track to developing dating relationships. how would you rate your relationship over the past month?” If the clients give the marriage an average rating of 5. given his or her current lack of funds. does that mean sometimes you are really arguing badly and other times not so much? What is happening differently at the times when you’re arguing less than a 5?” Another approach would be to ask. This is particularly useful in couples counseling. 6). “the therapist and client are able to have as clear a picture as possible of what a solution will look like even when the problem is vague. a client might indicate a desire to begin dating but complain that this is impossible. where 1 is “constantly arguing” and 10 is “getting along perfectly. such as through religious groups or community organizations. where such a question frequently elicits specific. while you were asleep. is actually a series of questions designed to elicit descriptions of specific behaviors that can serve as useful goals for therapy.. What are you currently doing that keeps you from being a 1 or a 2?” Note that the scaling question can be asked to introduce the notion of variability into the definition of problems and solutions.

” I have found it helpful. for example. “None of us is perfectly consistent. at certain times. Such exceptions can then be used to identify what each party was doing differently in the “close times. Not all therapists work in training settings. to elicit exceptions from clients by initially agreeing with their extreme self-presentation. as in “I don’t know why I feel anxious during examinations. The latter forms the basis for betweensession tasks in counseling. and Mrs. Such presentations are then reinforced if therapists adopt a subsequent problem focus. therapist teams conduct collegial consultations during sessions to evaluate what has occurred and construct promising interventions. and I can’t believe you have a perfect record of arguing every hour of the day. For instance. a client may spontaneously mention a sphere of life in which the problem pattern does not occur. tell me what you are doing differently with your friends that you are not doing in the examination situation. I never feel nervous. both as a way of tracking progress and as a way of focusing on the specific actions that can account for improvements over time.” so that each could do more of it between sessions and observe the results.102 The Art and Science of Brief Psychotherapies scaling may be conducted throughout therapy. A Consulting Break At the Brief Therapy Family Center in Milwaukee. The search for exceptions emphasizes client strengths by soliciting those instances when clients have not been enacting their problem patterns. For example. Tell me what you are doing differently on those occasions when you are not arguing. I replied that perhaps they could not benefit from counseling if their relationship were so devoid of love. of course.” The therapist can then respond with the inquiry “So. Both members of the couple became agitated at this remark because they did not wish to divorce and immediately gave examples of occasions when they manifested love and closeness. when Mr. When I am with my friends or out on a date. Wisconsin. Search for Exceptions The search for exceptions is the intervention perhaps most commonly associated with SFBT. A therapist might say. clients will say that they “always” argue or that they are “always” feeling depressed. Clients come to therapy focused on their problems and often frame their presentations in ways that suggest that they have identified with these problems.” Alternatively. and thus not all can make use of such . G entered therapy and indicated that they were growing too far apart.

the notion of a consulting break still has value in SFBT if the therapist thinks of the client as a collaborator. For you. The consultation. No small amount of initial client improvement in mood can be attributed to the internalization of such messages. conducted toward the end of the session. 2) These strengths are manifested even now. affirming the strengths of the client. wraps up what has been discussed so far and tries to establish consensus between therapist and client. 3) We can build on these strengths to achieve your goals. let’s summarize what’s been going on. You obviously want your marriage to work out. Both of you came in feeling frustrated with the marriage and feeling like you might be headed toward divorce. or otherwise reformulate them. I will also add a message of hope: “If we can learn from what you’re doing right in the marriage. G are alone and have time to talk together and share what you’re doing at school.Solution-Focused Brief Therapy 103 consultation. “I am impressed by the degree to which both of you have held on to your love for each other despite the stress you’ve been under. agree with them. however. Does that sound right to you?” Clients may then add to the therapist’s observations. When I asked about love in the marriage. . Remember when we remodeled the basement together? That was a headache. The consultation also ensures that the solution focus pursued by the counselor is indeed one that is user-friendly for clients. Mrs.” Not infrequently. I think we might be able to make some real strides toward your goal of rebuilding the loving times. For instance.” Such a consultation crystallizes solution behaviors and provides a natural bridge to between-session tasks during which clients can try more of what has worked for them. and I applaud you for that. Nonetheless. You told me that those have been some of the best times in your marriage. for you. Such a consulting break might take the following form: “Okay. when things seem to be at their worst. G. For example. G. you both told me that there were times—even now with the distance—when you do some loving and close things together. the close times seemed to happen when you took time off from studies and took vacations together. we also have felt closer when we’ve done projects together. it sounds as though the close times occur when you and Mr. Mr.” The compliment is designed to convey several messages: 1) You have real strengths. “Well. but we had a good time doing it together. A Message Including Compliments and a Task Very often the solution-focused therapist will conclude the session with compliments.

the client is often assigned the formula first session task. preferring instead to offer reassurance and a quick appointment. which de Shazer (1985) described as follows: “Between now and the next time we meet. so that you can describe to us next time. I am unlikely to suggest such a task. Hearing the initial presentation helps me determine whether the need for meeting is routine. urgent. where I see an average of 20–25 students a week. 137). Most important. Following the first meeting. Very often the task will be to note what happens when the client tries to do more of what has worked for him or her recently or to do something new that he or she imagines might work. This task must be doable and must draw on the exceptions and solutions noted during the meeting. This task extends the search for solutions and encourages clients to observe solutions that may not have been discussed during the prior meeting. Research suggests that such change is most likely to be reported if requested by the therapist. what happens in your family that you want to continue to have happen” (p. As a rule. helping therapists facilitate the construction of solutions.104 The Art and Science of Brief Psychotherapies In keeping with the goal focus of SFBT. it maintains the solution focus between sessions. It is ideal if the task of noticing presession change can be given at the time the appointment is first made. In my student counseling practice. Mapping the Practice of Solution-Focused Brief Therapy Both de Shazer (1988) and Walter and Peller (1992) offered useful flowcharts that map the practice of SFBT. favorable change that is already occurring and that is already within the client’s awareness represents a promising first focus for SFBT. I always set my own appointments. we would like you to observe. The following discussion will draw on these maps to describe SFBT as a series of steps and options. This is difficult to achieve in larger clinics where appointments are made by a secretary and easier in settings where therapists set their own appointments. Step One: Search for a Difference Option one: explore for presession change. clients will not necessarily report improvements in their state before entering counseling.) . even when these have occurred. or emergent and allows me to structure an initial task if this seems appropriate. (In an urgent or emergent situation. when the client has significant presenting distress. the compliment is followed by a concrete task to be attempted between sessions. reinforcing a new way of thinking about oneself.

were you doing to get your work done without procrastinating?” and “What. or if these cannot readily anchor solu- . as in “I tackled a doable amount of work. In SFBT. instead of the entire assignment. Option two: identify exceptions to the problem. for instance. It is not unusual for clients to experience difficulty with the sine-wave chart and other inquiries about presession change. and coaching to turn this mind-set around. It is helpful to make this a presuppositional question. however. simply by asking clients to identify positive changes that have occurred since the initial telephone call. the peaks will describe internal states that need to be investigated more concretely. this is not viewed as resistance and should never be a source of frustration for the therapist. This is particularly the case when two or more peaks describe similar changes. A different way to assess presession change is to request that clients complete a sine-wave chart. such as “Many people notice that they feel a little better by the time of their first meeting.Solution-Focused Brief Therapy 105 Many times. has been locked into a problem-based mind-set. of course. specifically. specifically. For instance. If the client cannot identify presession changes. The peaks of the chart represent occasions when they have been closest to their goals during the past 2 weeks. Have you noticed any positive changes since setting up our appointment?” One. however. and the valleys represent the occasions when they have been most distant from their goals. the client has been absorbed by his or her problem and. by definition. The search still can be conducted in the first session. were you doing when you were feeling confident about your work?” Multiple follow-up questions may be needed to frame the changes in action-oriented terms. A review of the peaks of the chart generally shows presession changes that can anchor solution talk in the session. modeling. Remember. a single solution pattern often underlies the multiple peaks. should always exercise discretion in making such an inquiry. a query about presession improvement could seem insensitive and hinder the development of rapport. the client is very tearful at the start of a first session. If. In such situations. Often.” This presession change may then form the basis for a “do more of what is working” task between the first and second meetings.” Follow-up questions would focus on “What. The chart generally takes little time to complete and is useful in establishing the notion of goals and the idea of variability in behaviors and outcomes. however. the busy schedules of clients and therapists do not permit detailed contact prior to the first meeting. a student with test anxiety may describe peaks in which “I got some work done without procrastinating” and “I felt confident about my work. It may take considerable encouragement.

This exercise is especially helpful in situations in which clients are mired in problem talk and cannot identify goals or presession changes. For example. exceptions could be solicited as “What. When the therapist asks for exceptions. specifically. building a sense of appreciation and cooperation. Exceptions to problems. on the other hand. the search for exceptions may focus on instances when things were better “even a little bit” (Walter and Peller 1992). When they report no good days as well. A client. the talk at that point is still problem focused. an adversarial situation has developed between members of a couple or between parents and children. In such circumstances. A presession change is a self-report of a positive behavior that is consonant with client goals. the husband indicated that he felt closest to his wife when she did not nag him about getting chores done around the home and instead just wrote the items down on a refrigerator to-do list. a scaling question might be used to capture their average degree of fighting. exclaimed that she no longer felt the need to nag because he was now spending enough time at home to read the refrigerator list! This led us to construct an initial task in which each party agreed to do more . acknowledging that there may not yet be any truly “good” days. may report no presession change. in response. “I’m feeling worse than ever. When the therapist asks about exceptions to problem patterns. The inquiry into exceptions. Walter and Peller 1992) and begins the search for exceptions to presenting problems. for example. with considerable emphasis on blaming and defending. the therapist changes “frames” (de Shazer 1988. The wife. in a recent session. are you doing on those occasions when your fighting is less than an 8?” I have found it helpful to ask clients to give a separate scaling rating for their best days and worst days. When clients describe presession changes. not as a manifestation of a desire to avoid change. A couple.106 The Art and Science of Brief Psychotherapies tions at the present time. each participant in therapy may be able to identify solution behaviors used by the others. indicating. If the couple reports fighting of 8 on a 10-point scale. may state that they have not been able to get along for the past several months and have made no recent changes in a positive direction. for instance. this is taken as a genuine expression of the individual’s experience. are a step behind this from a solution-focused perspective. This then leads naturally to exception questions of “What are you doing differently when your fighting is a 5 rather than an 8?” The search for exceptions can be especially helpful in couple therapy and in therapy for children brought by their parents. Very often. indeed.” Once again. is a strategy for shifting problem talk into solution talk. they are engaged in solution talk. Each party has been focused on the shortcomings of the other.

As mentioned earlier. even random efforts at “doing something different” are apt to produce spontaneous exceptions that can then become deliberate. In the hypothetical frame (Walter and Peller 1992). I then inquire what . Indeed. This then becomes an opportunity to explore what. These are most likely to be situations in which the individual is very much stuck in a problem focus. the client was doing on the exceptional occasion so that it can be constructed as a potential solution. For example. On occasion. indeed. underscoring the importance of tasks that encourage novelty on the part of the client. your problem were solved. clients try to do something different and thereby bring themselves closer to their goals.Solution-Focused Brief Therapy 107 of what worked for the other. Many times. The shift toward solution talk helped to defuse the resentments that had accumulated and start a rebuilding of trust between the parties. the client may describe the exception as something that “just happened” or that occurred as the result of someone else’s actions. de Shazer (1988) made the distinction between deliberate and spontaneous exceptions. in the course of therapy. “Imagine that the problems between the two of you have been solved. be the result of actions that are reproducible. I sometimes have had success asking for the name of a person he or she admires greatly. what would you be doing differently?” When a client’s imagination has been lacking. the search for hypothetical solutions can generate ideas that form the basis for between-session solution-based tasks. a client may spontaneously stumble on an exception. In such situations. the therapist might ask. Let us say that our couple cannot think of any exceptions to their pattern of fighting or that the exceptions they generate are equally problematic (“We didn’t argue because we were ignoring each other”). When. Option three: generate hypothetical solutions. Questions that reframe the exception in active terms can elicit useful information that assists with the construction of solutions. specifically. What will each of you be doing differently?” or “If. the therapist enters a “cheerleading” mode and encourages further enactment of the solution. A follow-up question might be “Do you always feel better when someone says something nice to you? What might you have been doing to be more open to positive remarks on this occasion?” The key is to help clients see that exceptions may not be random events but could. by a miracle. the client might report that he or she felt less depressed on a particular day because of a nice thing that someone said to him or her. the language used to frame exceptions is crucial in using these in therapy. On other occasions. clients cannot identify presession change and are unable to identify exceptions to problem patterns.

occurs between sessions. here-and-now tasks that can be enacted between sessions. The therapist is most likely to elicit such examples when questions have a presuppositional quality.108 The Art and Science of Brief Psychotherapies that admired person might be doing or saying in the problematic situation. or ethnic groups different from the therapist’s. such inquiries encourage clients to identify occasions when the hypothesized solution has been happening just a little bit. Much of the actual work of SFBT. cueing the client to scan for such occasions. Step Two: Assign Tasks The preceding three options—identifying presession changes. here-and-now goals. When exceptions are identified that are deliberate. in this volume). In one memorable counseling session several years ago. when the client attempts to make use of the solutions constructed in therapy. When the exceptions are spontaneous. This notion of “a little bit” frees the client to focus on pieces of solutions that can become a basis for initial counseling tasks. This can be especially helpful in multicultural counseling with international clients and clients from racial. Solution-focused responses to incidents of campus racism consisted of role-playing the hypothetical responses of the grandmother.” The presupposition is that a little piece of the hypothetical solution has been occurring already. the initial task may be to have the client figure out how the exception occurred. and hypothetical solutions—are ways of shifting problem talk to solution talk in counseling and defining practical. invoking her spirit and enacting her virtues. however. Bridging the exploration of solutions in session and their enactment between sessions is the assignment of tasks. religious. Once this infor- . by watching for it in the future. the homework task typically takes the form of “do more of it” (p. 64). Using an admired person to generate hypothetical solutions has the disadvantage of not rooting the initial search in the client’s direct experience but does very much stay within the values and priorities of the client. As Walter and Peller (1992) noted. Walter and Peller (1992) described three kinds of therapeutic tasks arising from a solution focus. Chapter 9. Instead of asking. “Tell me of a time when you have done a little of this recently. inquiring about hypothetical solutions in counseling creates a bridge from imagined responses to concrete. “Have you done anything like this recently?” the counselor might instruct. the client reported that her grandmother was a revered figure because of her wisdom and strength of character. exceptions. Toward that end. The focus on an admired person often generates culture-specific solutions that are uniquely valid for the client (see Echemendía and Núñez.

helping clients identify what they are doing constructively. When these steps have been the result of deliberate efforts to break old patterns. the therapist has some reassurance that the solution pattern is within the conscious control of the client and therefore is doable as a task. the specific task will take the form of extending actions that already have been taken: “I notice that standing up for yourself worked very well in your work setting. I have found journal writing or the use of the sine-wave chart to be a helpful tool for tasks involving the exploration of solution patterns. and recognize that those patterns had favorable outcomes and that the patterns are within their control. would be to have the couple be on the lookout for future close occasions and note carefully the preceding actions and interactions.Solution-Focused Brief Therapy 109 mation is obtained. When an exception is spontaneous. Clients often feel that they have no control over their emotional responses and thus feel helpless. Many times. then the assigned task calls for the client to enact a small piece of this solution. Perhaps that is something we could try with your co-workers as well and see what happens. Once the positive action patterns can be singled out. the spontaneous exception can become deliberate. In each case. therapists help to instill a greater sense of internal control. You let your supervisor know exactly what you were thinking and feeling in a cooperative. constructive way. Option one: do more of it. A couple might notice that they felt close on a particular evening but could be unable to verbalize what each person was doing differently on this occasion. The initial task. . The performance of these tasks then typically becomes the initial topic for the next session. which is then reinforced by the between-session tasks. By highlighting that they do have control over actions that generate new feeling states. Option two: figure out how to do it. Clients are asked to “take your emotional temperature” several times during the day and notice those occasions when they are feeling especially good. Journal entries then include the actions and thoughts accompanying these good-feeling times. If the client develops a hypothetical solution. This can occur as the result of either noticing a presession change or identifying an exception to problem patterns.” Crucial to such “do more of it” task assignment is that clients recognize their solution patterns. clients may be puzzled as to how they were able to avoid their usual problem patterns. they can form the basis for a subsequent “do more of it” task. then. The most clear-cut tasks to assign as homework emerge when clients are already aware of steps they are taking to bring them closer to their goals. the client is asked to make use of the solution talk within sessions during the time between sessions.

the subsequent conversation can explore what. However. the therapist should not require the client to create reasonable expectations for all upcoming work. If. in the next session. To allay these concerns. however. this small part will be a solution element well within the client’s control. Particular care should be taken to make the task doable. a student imagined that she would not have an anxiety attack if she were with her friends and family members. where 1 is “totally unreasonable expectations” and 10 is “totally reasonable ones. if clients report that they implemented the task as discussed in the prior session but found no results. For instance. they have successfully performed much of the defined task. clients will expect perfection at the outset and report failure when. to determine whether this is indeed something worthy of further enactment. In a recent session. then it is generally useful to reassure them that change does not typically happen all at once or right away. there may be considerable doubt about its value. the therapist may simply ask the client to enact a small part of the solution pattern and observe the results.” how would you rate those times when you tried to do something different? How would you rate those times when you continued to do things the old way?” If a scaling difference is reported. in fact. We constructed a task in which she could touch base with them through an online instant messenger service and by telephone and achieve a little of the sense of interpersonal connection. contributing to a greater sense of security. There also may be doubt as to whether it can be enacted on demand. a scaling question is often quite useful. This helped her feel that she could be with supportive others at any time of the day or week.” In the following session. sometimes a change . specifically. She lamented that all of these people lived far away and could not be with her. Generally. if the client hypothesizes a solution in which he or she might overcome anxiety by moderating his or her work expectations. It is important that such tasks be defined as clearly and specifically as possible. The scaling question might then be “On a scale of 1 to 10. making use of the client’s language and drawing on the client’s experience. clients indicate that they were not successful in implementing any of these tasks. Many times. As Walter and Peller (1992) noted. I make the task “something I would like you to try during the week. occurred that made the little bit of difference and how this might be extended. it might then be possible to contrast those occasions when the client attempted the solution with those when he or she did not. the assigned task could be to identify an upcoming assignment and create reasonable expectations for working on this.110 The Art and Science of Brief Psychotherapies Option three: try a small piece of the solution. When the client has identified a hypothetical solution. Many times.

became the basis for our solution task. This student’s therapy illustrates how solutions can be constructed from a variety of sources. what were you doing this past week that was different from before?” or feedback could occur in response to a client’s reported progress. This. two classmates actually sought him out when they noticed his Bible. it is possible to reframe much of such psychodynamic work in solution-focused terms. Step Three: Provide Feedback Walter and Peller (1992) used the term cheerleading to capture the positive support and encouragement provided by therapists when clients move closer to their goals by enacting solutions. Such feedback might be offered early in a session. the client might indicate that his or her anxiety was still very high immediately before taking the test but. he actually seemed to become more relaxed in our interaction. he found that his anxiety declined noticeably. as in “You’re looking and sounding much more lively than last week. he opened up considerably about his beliefs and the ways in which these reassured him. Although SFBT does not typically feature an examination of interactions between clients and therapists in the manner of short-term psychodynamic work. indeed. Once it was clear that I did not challenge his faith. Feedback of this kind often acknowledges that a client .Solution-Focused Brief Therapy 111 may have occurred without the client’s recognition. To his surprise. as he decided to see if bringing his Bible to class and risking the reactions of classmates could yield similar relief. Indeed. with the use of the scaling question. I then asked him to rate his comfort level in the session with me. I noticed that as he was talking to me about the use of his Bible. he acknowledged feeling much less anxiety than at the start of our session. that there were periods during the studying when anxiety was markedly reduced. For instance. and together they formed an extracurricular group on campus. then. occasions when the client attempts to do something different in the helping relationship can form the basis for helpful solutions. He knew that I did not share his religion and was concerned that I might look down on this use of his faith. as clients break their problem patterns by enacting adaptive solutions in the helping relationship and then generalizing these to other interpersonal contexts. and. including positive interactions with the therapist. The follow-up inquiry can then focus on “What might you be doing during your studying that we can bring into the examination room?” One client in this very situation sheepishly admitted to me that he studied at home with his Bible open because it gave him inspiration and strength. Interestingly. Armed with his faith during examinations.

linear path. even amid general discouragement. Single “booster” sessions are often helpful in such circumstances. scanning her body for imperfections and convincing herself that she was ugly and grotesque. To an outside observer. With this feedback. Summary Case Illustration: Ms. This. only later to face a situation that elicits the old problem-based modes. By all accounts. especially when client progress has been modest. . talented student who interacted well with patients and whose fund of knowledge exceeded expectations. it is generally possible to ask clients what they are doing to stay sane in the situation and to elicit positive coping efforts. if ever. During these periods. I’s experience of herself. I. the feedback is both reassuring and sympathetic. I was also attractive and personable and had many friends on campus. generally focusing on her body and her weight. I was in the third year of her medical curriculum and had just begun her clinical work. talk in terms of “termination. Finding small steps of progress. She reported occasional bulimic episodes since her early years in college. Some of the feedback is more of the reassuring variety. was not Ms. however. clients can often enact solutions on their own. “You’ve made an excellent start”—thereby building momentum for attempting further progress. Ms. She spent many hours in front of a mirror in this self-critical mode. Walter and Peller (1992) emphasized the importance of normalizing setbacks. Ms. can anchor efforts to extend these modest steps into larger strides. It is not unusual for individuals to make steady progress. a medical student. allowing clients to define solutions even in the most trying circumstances. Her greatest fear was that she would never be able to maintain a romantic relationship with a man. The focus on solutions should in no way interfere with basic empathy for the discouragements that clients may experience.” preferring instead to transition meetings to an “as needed” basis. she was a motivated. The tenacity with which the therapist remains grounded in assets and strengths often becomes contagious. came to our first session complaining of an “out of control” problem with her eating. perhaps out of discouragement over a setback. I rarely. Such intermittent intervention allows therapy to be an ongoing developmental resource for clients rather than a one-time treatment. I Ms. reducing the need for weekly sessions. Even when problems are overwhelming. letting clients know that success is not a simple.112 The Art and Science of Brief Psychotherapies has not completely attained his or her goal—for example. I led a charmed life. When clients come to a session with renewed problem talk. Ms. she criticized herself unmercifully.

I readily responded that she felt good about herself when she was working with patients. She did acknowledge. completely disgusted with herself.” I suggested to Ms. “Looking over the last few weeks. “And what happened on those great days in the hospital that made the eating better than usual?” “I don’t know.” “OK. I did not meet formal diagnostic criteria for an eating disorder and was not experiencing a diagnosable mood disorder. Her binge eating had returned. I offered. She presented herself as a woman out of control.Solution-Focused Brief Therapy 113 In a desperate attempt to control her weight and improve her body image.” she responded hesitantly. “The time I’m thinking about.” Ms.” I followed.” Ms. where would you stand?” “Maybe an 8. As Ms. I didn’t even think about it. Afterward. The only okay times were after I had a great day on the floors. you would be doing what? What would I observe?” “I would just be eating normally. the way you do in medicine?” “I guess I would like myself better. I to identify any occasions since setting up the appointment with me in which she felt more “in control. the patient called for me before being discharged and told me how much I had helped her and what a great doctor I’ll become. eating only enough to avoid passing out. I had spent an unusually large amount of time in front of the mirror. and she became more animated in her speech. These bingeing episodes left her feeling profoundly guilty. and she had already developed confidence in understanding her patients’ medical conditions. because she found that repulsive. Ms. without giving myself a big guilt trip about it. This raised my confidence that BSFT might be appropriate. I went home and ate some leftover food and then realized that I hadn’t even made a big deal about the eating. I felt great. that she was able to refrain from purging the food. “What would I observe if you were on your way toward feeling in control. Information that I gathered in the initial session suggested that Ms.” . “And how would I know that you were feeling better about yourself? What would I be seeing if I were that fly on the wall?” “I wouldn’t be so hard on myself. she found herself voraciously turning to food for relief and gratification. where 1 represents being completely in control of your eating and 10 means having no control whatever. I searched for presession change during our first meeting by asking Ms. her mood brightened noticeably. “I would just eat when I was hungry. I needed her to be more specific. however.” Ms. “And instead of being hard on yourself. As her self-criticism and depressed mood deepened.” This struck my interest. I responded. “It’s been really bad lately. I answered. I. I said with feeling. however. Ms. how would you rate your eating? If you imagine a 10-point scale.” Ms. I spoke of her clinical experiences. triggering further self-criticism. disrupting her efforts at studying.” Ms. She knew that she was effective with other people. In the days prior to contacting me. “Suppose I were a fly on the wall of your apartment. I would withhold food from herself for an extended time.

I. “They respond so well to nurturing. I replied.” Ms. “Too well! The last clerkship was really hard. I laughed.” Ms. “What are you imagining?” I asked.114 The Art and Science of Brief Psychotherapies “So when you felt like Dr. “She seems so small. I never have any problem eating. and we went out for pizza afterward.” “And what are you saying to little Marie?” . they don’t have control over anything happening to them. “That’s funny. I asked Ms. it’s a lot harder to hold on to those good feelings. I want to help her. Usually I feel good about being done with the test. “What specialty are you thinking of entering?” I suddenly asked.” I offered. “She’s in bed and almost all the way under the covers. not knowing what’s wrong with them.” “And what are you doing with little Marie?” I asked. much as I assumed it was during her working day. But she needed to eat to stay healthy. all those strange people. maybe. When you come home and you’re just plain Ms. I suggested that she imagine that she had a little girl assigned to her as a patient. Ms. what you do. and I ate plenty. It was disgusting. and what you know. I knows how to eat pretty well!” Ms. “And you eat well when you go out with them?” Ms.” Ms. reaching out to her?” Ms. I’s response was swift. I love working with kids. I’s first name]. someone who cares about them. A good doctor who can be reassuring and fun and caring can make all the difference in the world. “Do you think you’d be open to trying a little experiment with me?” I asked.” By this time. “A little bit the next day. and I’m just happy to go out with friends and enjoy myself. The little girl’s name was Marie [Ms. I laughed again. I replied. her tone was quite lively and animated. I.” “I have a feeling you’d be good with kids. I seemed attentive. They feel so helpless. It’s very scary for children in a doctor’s office and especially in the hospital.” “But you didn’t feel guilty?” I asked.” “These are your medical school friends?” I inquired. Ms.” “Hmmm…it sounds as though Dr. or if it will ever get better. “Can you see little Marie in your mind’s eye?” I asked. “I’m sitting at the side of her bed looking down at her. I’m holding her hand with one hand and giving her a little food with the other. I nodded.” Ms. “Sure. She was very scared and nervous and didn’t want to eat anything. “After a big test. I agreed. It’s what I’ve always wanted to do. “But we had fun after the test.” she responded. She seemed much calmer than at the outset of our meeting. “Can you imagine yourself helping her. “Pediatrics. “you didn’t beat up on yourself. We had a couple of lunches sponsored by the drug representatives. You could value yourself for who you are. I to close her eyes and focus her thoughts on her deep and slow breathing.” I offered. I seemed deep in reverie.

Ms. I don’t want you to think about eating. I.” For a few moments. I when you get home. I. In subsequent weeks. based on one of her imagery sessions. and she agreed to give it a try. because you have a patient to take care of at your house. “When you come home at the end of each day. and she’s been having a hard time feeling good about herself. “It’s OK. The exercise came to her with some difficulty at first but became easier when she imagined herself as a little child before sitting down for a meal. Ms. and when you get home from your clinical rotation. it’s OK. I want you to stay as Dr. I complimented her sensitivity. I was silent. caring person. When she looked at me directly. I.” Ms. She caught herself starting to examine herself in the mirror but instead kept her white coat on and decided to take care of her patient Ms. I reported that eating in a healthy way still required some forethought but that it was coming more naturally.” she whispered. and someone who had been well nurtured as a child. “Do you think you can be your own patient now? Do you think you could take care of yourself the way you imagined taking care of the little child?” “How do you mean?” Ms. first thing in the morning when you put on your white coat. The following week. Shortly after this episode. I by offering a small snack. I simply helped her apply those talents and experiences to herself.” She found that being in the role of a nurturing physician caring for a child in pain was easier for her than taking care of an adult. I emphasized to Ms. she found. was helpful in her assigned task of taking care of “patient Ms. Your job.” The idea intrigued Ms. I asked quizzically. Afterward. a capable physician. Interestingly. Ms. I agreed. she was able to recall a lullaby her mother had sung to her when she was young. I want you to keep your white coat on. she felt no lingering guilt. she reported no episodes of binge eating. Conclusion Readers will recognize many elements of SFBT in the case example of Ms. I began a dating relationship—the first in more than a year—and reported feeling much better about herself. and she takes it out on her eating. the use of the miracle . Playing that lullaby in her head. “It sounds as though you’ll be very good to your patients. reinforcing a new sense of control. You really make them feel secure. including the search for presession change. I’s voice cracked.Solution-Focused Brief Therapy 115 Ms. “I love you. I that I had not taught her to do anything new. She had always been a good. Her name is Ms. Thinking of herself as a vulnerable child enabled her to mobilize her physician-self and the caring responses associated with that role. I. is to feed Ms. Make sure you have your stethoscope with you and all your pens and books. a few tears welling in her eyes. It’ll be OK. A major step of progress came when she was criticized during a clinical rotation and returned home feeling miserable. She takes it out on her body. I want you to think about taking care of your patient Ms. I and take care of her. I and offering her some food and support.

it was her solid sense of herself as a student-physician and her willingness to enact the solution on a daily basis that allowed for the relatively rapid change. 139). who used imagery and shifts in client experiencing to anchor new behavior patterns. In an insightful observation. and to practitioners such as Erickson and Lankton. Determine how you are solution focused in your best moments as a therapist. examine all therapies and identify the ways in which they introduce and reinforce solutions: departures from old. You have taken an excellent step by exposing yourself to a variety of short-term approaches. on your desire to move toward your goals as a brief therapist. I’s therapy was the shift in her tone of voice from the very start of our session—when she was problemfocused—to the portion of the session when she described her work as a medical student and her love of pediatrics. The key. we structured the conversation in a way that identified and reinforced her strengths as a physician-to-be. who emphasize minimal interventions to interrupt problem patterns. We did not explore her negative feelings about herself. Such elements may strike the reader as lying outside the purview of SFBT proper. de Shazer (1988) noted that many of his solution-focused interventions with clients were paced in an Ericksonian manner and even elicited trancelike responses (p. was to mobilize this “doctor-self” in the context of eating.116 The Art and Science of Brief Psychotherapies and scaling questions. Ultimately. A key nonverbal element in Ms. Between now and when we should run into each other again. Rather. Rather. Once you discover how you are best at cultivating change. From the outset. the reader. but I think not. the goal of the therapy was not to explore the historical and contemporary roots of her eating complaints. In conclusion. Readers will recognize elements from other approaches to therapy in the example as well. in their personal or sociological contexts. My working hypothesis was that this brightened tone reflected a greater sense of perceived control and an enhanced experience of self. problem patterns. Rather than view SFBT as a completely separate and unique therapy. My work owes more than a little inspiration to the strategic therapists. then. I would like to suggest a task. Such shifts of state appear to be powerful tools in helping clients shift from problem to solution talk. try doing more of that in your upcoming ses- . We did not refer to an “eating disorder” or “eating problems” at all. and the emphasis on exceptions to the problem pattern. in your own unique way. I borrowed her phrase of being “in control” as an anchor for her positive goals. I would like to congratulate you. Reframing eating as a clinical activity allowed her to take a solution from her training and “do more of it” in her personal life. If food could be viewed as a medication—something to be administered by a caring physician—eating would now fit into her strengths.

DiClemente CC: The transtheoretical approach. 1996. 1996. pp 163–200 Simon D: Crafting consciousness through form: solution-focused therapy as a spiritual path. New York. Edited by Miller SD. 1992 Steenbarger BN: Duration and outcome in psychotherapy: an integrative review. pp 335–350 O’Hanlon W. pp 272–298 de Shazer S: Keys to Solution in Brief Therapy. Edited by Norcross JC. Hubble MA. New York. Weiner-Davis M: In Search of Solutions: A New Direction in Psychotherapy. Edited by Miller SD. Edited by Miller SD. CA. Edited by Miller SD. Jossey-Bass. et al: Research on the process of solution-focused therapy. WW Norton. pp 27–43 McKeel AJ: A clinician’s guide to research on solution-focused brief therapy. in Handbook of Solution-Focused Brief Therapy. 2000 Held BS: Solution-focused therapy and the postmodern: a critical analysis. pp 251–271 Metcalf L. Eisengart S: Solution-focused brief therapy: a review of the outcome research. in Handbook of Solution-Focused Brief Therapy. CA. in Handbook of Solution-Focused Brief Therapy. New York. 1994 Walter JL. in Handbook of Solution-Focused Brief Therapy. in Handbook of Solution-Focused Brief Therapy. Hubble MA. CA. 1989 Prochaska JO. San Francisco.Solution-Focused Brief Therapy 117 sions. Jossey-Bass. Duncan BL. Jossey-Bass. et al: What works in solution-focused brief therapy: a qualitative analysis of client and therapist perceptions. Duncan BL. Edited by Miller SD. in Handbook of Solution-Focused Brief Therapy. Hubble MA. 1992 Walter JL. Palenzuela DL. pp 9–26 . Fam Process 39:477–498. Perhaps your clients will be more likely to find their solutions once you have targeted your own. New York. Hubble MA. Thomas FN. New York. 1996. JosseyBass. San Francisco. 1996. Hubble MA. 1986. Duncan BL. Edited by Miller SD. Duncan BL. Hubble MA. Hubble MA. in Handbook of Solution-Focused Brief Therapy. San Francisco. WW Norton. CA. Morejon AR. Prof Psychol Res Pr 25:111–119. Jossey-Bass. Duncan BL. Jossey-Bass. pp 299–334 DeJong P. Hopwood LE: Outcome research on treatment conducted at the Brief Family Therapy Center. 1985 de Shazer S: Clues: Investigating Solutions in Brief Therapy. References Beyebach M. San Francisco. Brunner/Mazel. Couns Psychol 20:403–450. San Francisco. in Handbook of Eclectic Psychotherapy. Duncan BL. San Francisco. pp 44–64 Steenbarger BN: Toward science-practice integration in brief counseling and therapy. Duncan BL. 1996. Peller JE: Rethinking our assumptions: assuming anew in a postmodern world. Duncan BL. Jossey-Bass. Brunner/Mazel. Peller JE: Becoming Solution-Focused in Brief Therapy. 1996. 1988 Gingerich WJ. CA. San Francisco. Edited by Miller SD. 1996. CA. CA. WW Norton.

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IPT was codified in a manual in 1984 (Klerman et al. nterpersonal psychotherapy (IPT) is a time-limited.5 Brief Interpersonal Psychotherapy Scott Stuart. by helping patients to either modify their interpersonal relationships or change their expectations about them. 1984). IPT has been shown to be superior to placebo and as effective as the antidepressant imipramine and cognitive-behavioral therapy for mild to 119 . M. I Empirical Support for Efficacy Originally developed as a research treatment for major depression. IPT also assists patients in improving their social support network so that they can better manage their current interpersonal distress. IPT focuses specifically on interpersonal relationships to bring about change.D. dynamically informed psychotherapy that aims to alleviate patients’ suffering and improve their interpersonal functioning. Since then.

including postpartum (O’Hara et al. Essential Characteristics IPT is characterized by three primary elements: 1) IPT focuses specifically on interpersonal relationships as a point of intervention. dysthymic disorder. Kupfer et al. IPT reflects the best of both empirical research and clinical experience and continues to incorporate changes that improve the treatment. the use of IPT has been described with groups. In a 3-year follow-up study of patients with recurrent depression (E. IPT encourages clinicians to use their clinical judgment to modify treatment in order to maximally benefit patients. as compared with about 40 weeks with placebo. social phobia. with IPT as a viable alternative for patients who do not want or who cannot tolerate medication. 2) IPT is time limited when used as an acute treatment. 1990). adolescent depression. Finally. Thus. . Frank et al. 2000) and antenatal depression. IPT is also effective for perinatal depression. the depressed phase of bipolar disorder. and eating disorders.120 The Art and Science of Brief Psychotherapies moderate depression over a 16-week course (Elkin et al. 1989). depression in HIVpositive patients. In addition. Current research is examining the effectiveness of IPT in depression associated with cardiac disease. and 3) the interventions used in IPT do not directly address the transference relationship as it develops in therapy (Stuart and Robertson 2003). and in a family practice setting. IPT has been shown to be efficacious in several psychiatric disorders. its use has broadened to include not only a variety of well-specified DSM-IV-TR (American Psychiatric Association 2000) diagnoses but also a variety of interpersonal problems (Stuart and Robertson 2003). patients remained depression free for 120–130 weeks with imipramine and for 75–80 weeks with IPT. with couples. Frank and Spanier 1995. 1992). as clinical experience with IPT has increased. Rather than being designed to be applied in a strict manualized form in which the clinician is required to precisely follow a specified treatment protocol. and somatization disorder. Excellent reviews of this research have been conducted by Weissman and colleagues (2000) and Stuart and Robertson (2003). Neither therapy was as effective as imipramine for severe depression. A current opinion is that recurrent depression should be treated with maintenance antidepressant medication (E. including geriatric depression. the practice of IPT should be based on equal measures of empirical research and experience-based clinical judgment.

Rather. Past experiences. For example. The second focus is helping patients to build or better use their extended social support networks so that they are better able to muster the interpersonal support needed to help them deal with the crises that precipitated their distress. and personality characteristics are all important in assessing suitability for treatment. they are taken as a given for a particular patient. This latter point leads to a corollary of the IPT approach: by virtue of its time limit and its focus on here-and-now interpersonal functioning. or from colleagues at work). connecting with and asking for support from other friends who have had children. Resolution of the particular interpersonal conflicts..g. are not a major focus of intervention. in which the focus of treatment is on understanding the contribution of early life experiences to psychological functioning. would then lead to symptomatic improvement. this approach is extremely well suited for the treatment of women who may be experiencing an episode of postpartum depression (O’Hara et al. One focus is the difficulties and changes in relationships that patients are experiencing. IPT focuses on helping patients improve their communication and social support in the present. defense mechanisms. change in these constructs is not presumed to occur in IPT. 1979) and psychoanalytically oriented psychotherapy. although clearly influencing current functioning.Brief Interpersonal Psychotherapy 121 Interpersonal Relationships IPT is based on the premise that interpersonal distress is intimately connected with psychological symptoms. with the aim of helping patients either to improve communication within those relationships or to change their expectations about those relationships. IPT therefore stands in contrast to treatments such as cognitive therapy (Beck et al. in which the focus of treatment is the patient’s internally based cognitions. the foci of treatment are twofold. from extended-family members. 2000). In contrast to analytically oriented treatments. along with improved interpersonal support while the role transition is being negotiated. Although ego strength. Many perinatal women state that their distress is linked to difficulties in their relationships with their partners or in making the transition from working woman to mother. A therapist using IPT would help the patient to resolve conflicts with her partner over issues such as division of child-care labor and also would assist the woman to garner more support from her social network (e. IPT seeks to resolve psychiatric symptoms rather than to change underlying dynamic structures. Thus. IPT focuses on the patient’s interpersonal communications with others in his or her social sphere. In contrast to cognitive therapy. and the question that drives the therapist’s interventions is “Given this particular patient’s .

Mr.122 The Art and Science of Brief Psychotherapies personality style. Although her expectations about what he could and should contribute appeared to be realistic. Several of her colleagues who had children shared their similar experiences of ambivalence about returning to work. it became apparent that rather than directly asking her husband for help. during which these two issues would be addressed. how can he or she be helped to improve here-and-now interpersonal relationships and build a more effective social support network?” Case Example: Mrs. She described feelings of worthlessness. Mrs. Mrs. Work on communicating more effectively with her husband was a major part of the treatment. during which both Mr. Her work situation was addressed in three ways. low energy. She also identified that maintaining her social . guilt. A contract to meet for 12 sessions of IPT was established. J spontaneously identified that her distress was related to two issues. crying spells. and although she did want to return to work eventually. she did not feel prepared to do so quite so soon. J were able to give each other more direct feedback about their expectations. As Mrs. J with nearly all of this work. As Mrs. and low mood. Mr. J was expecting him to “know” what help she wanted without her having to ask. and as she began to resolve her conflict about returning to work. anhedonia. J was able to respond and meet her needs more effectively. she began contacting her friends from work and found that they were quite willing to maintain contact with her outside of work. J. she began developing new social supports in a “new mothers” group. she elected to take an additional 6 months of maternity leave without pay. J also participated in several sessions. her maternity leave was ending in 3 weeks. after consulting with her husband about the financial consequences of the decision. presented with symptoms of depression at 9 weeks’ postpartum. J’s communication with her husband improved. J Mrs. her symptoms improved quite rapidly. and Mrs. she identified that she was having a great deal of conflict about returning to work. Second. and early life experiences. First. as well as her attempts to enlist him in child-care activities. She reported no history of psychiatric illness. J’s communication improved. she had an escalating conflict with her husband: prior to the arrival of their child. Third. which included a great deal of communication analysis and role-playing. which she found very supportive. J’s expectations regarding her husband were explored. ego strength. Initially concerned about losing her social contacts at work if she were to take more time for maternity leave. First. but he had actually been working longer hours since the birth and had left Mrs. a 27-year-old woman. Second. The child was her first. her ambivalence about returning to work was framed as a normal experience encountered by many new mothers. and her pregnancy and delivery were unremarkable. She would typically withdraw in silence when he failed to anticipate her needs. defense mechanisms. Mrs. which included some women who had chosen to stay at home with their children rather than return to work. he had agreed to assist with child care.

a course of 12–20 sessions tapered over time is effective (Stuart and Robertson 2003). K reported that his two brothers and parents all lived some distance away. When employed. and felt quite happy with his life before his layoff. followed by a gradual increase in the time between sessions as the patient improves. came for help after having been laid off from his job. Despite . Case Example: Mr. was used. particularly of potential job interviews. K’s avoidant style. 1984. K’s examples of good communication. and he was not in a romantic relationship. K Mr. a 37-year-old computer programmer. Stuart and Robertson 2003) and also influences both patient and therapist to maintain their focus primarily on here-andnow interpersonal problems rather than working on issues from the patient’s past. K about his interpersonal communication. however. Time Limit The second characteristic of IPT is that it is time limited in the acute phase of treatment. Mr. His depressive symptoms had gradually increased as he realized that he was going to have to seek new employment. K reported reduced anxiety. such that weekly sessions may be used for 6–10 weeks. K. Later in the therapy. Finally. K’s work interactions were examined for communication patterns. with the therapist giving direct constructive feedback to Mr. He was clear. Detailed descriptions of Mr. for the acute treatment of depression and other major psychiatric illnesses. he had little contact with colleagues at work and very little social support in other settings. He reported dating rarely. A contract should be established with the patient to end acute treatment after a specified number of sessions. Having a definitive end point often pushes patients to make changes in their relationships more quickly (Klerman et al. particularly because it was intellectually challenging with little need for personal contact. In general.Brief Interpersonal Psychotherapy 123 support from colleagues at work along with the new support she had developed with the new mothers group was extremely helpful. role-playing. Although Mr. the time frame is helpful in preventing the therapy from moving from a symptom-focused treatment to one that is based on the development of the transference relationship. The therapist took particular care to be empathic and to ensure that a good therapeutic alliance was established given Mr. that he had enjoyed his job. with the therapist strongly reinforcing Mr. He reported a lifelong pattern of social avoidance and was fearfully anticipating the interviewing process for a new job. He had not been able to even put together a resumé prior to entering therapy. he continued to be very reluctant to apply for jobs and go through the interview process. He had occasional telephone contact but saw them only during holidays.

An explanation of the use of transference in IPT is necessary to fully appreciate the nature of the treatment. by session 5. the therapist thought that Mr. By session 10. However. He was well qualified and received several interview offers. he still had not scheduled any interviews. the therapist’s experience of transference is crucial in understanding the patient’s interpersonal world and attachment style and in formulating questions about the patient’s relationships outside of therapy. he would not obtain maximum benefit from treatment without having completed several interviews. K would benefit most from the treatment if he had completed several interviews by the time IPT ended: role-playing was helpful. K begin the interview process. or use of more subtle pleas to the therapist for help or reassurance. applied for any jobs. K had not yet been offered a job at the conclusion of treatment. Mr. it was imperative that Mr. K positive feedback for the productive ways in which he communicated. manifested as difficulty in ending sessions. the transference relationship is not addressed directly by the therapist. The Transference Relationship The third characteristic of IPT is the absence of interventions that address the transference aspects of the therapeutic relationship. and they used more role-playing to examine different approaches that he might have used. This trait is shared with cognitive-behavioral therapy and solution-focused therapies. This transference relationship should in- . he had not. K did send applications out to several computer firms. The transference experience also should inform the therapist about potential problems in therapy and help predict the likely outcome of treatment. As an illustration. K’s communication and the management of his anxiety during the completed interview. The therapist. Despite his anxiety. Although Mr. Given that time frame. K was improving. Both agreed on a deadline of getting job applications out within the next week. With only four sessions left. The therapist gave Mr. nonetheless emphasized that he and Mr. He also acknowledged that he would likely not have applied for jobs and gone through the interviews without the therapist’s “gentle” push. K had completed one interview and had scheduled two additional interviews. K’s difficulties. The therapist once again noted that although Mr. calls to the therapist between sessions. By session 8. It is acknowledged that transference is a universal phenomenon in all psychotherapy. In IPT. empathic to Mr. he reported a great deal of symptom relief and increased confidence about being interviewed. K had agreed that the therapy would last 12 weeks.124 The Art and Science of Brief Psychotherapies conversations in therapy about the need to do this. but it clearly distinguishes IPT from most dynamically oriented therapies. The therapist used the opportunity to examine in great detail Mr. however. consider a patient who forms a dependent relationship with the therapist. Mr. but there was no substitute for the real thing.

He was also angry with his wife of 30 years because she had begun refusing to help him administer his insulin shots and had told him to “stop being a baby. L felt that she did not understand how much he was suffering and was refusing to be supportive. To do so detracts from the focus on symptom reduction and rapid improvement in interpersonal functioning. Mr. and reacts when others are not responsive to his or her needs. and 3) have exhausted others with persistent calls for help.” Mr. The diagnosis of diabetes had exacerbated his fears about other physical problems. ends relationships. He often thought that something was physically wrong and recognized that he needed a great deal of reassurance at times. the basis of IPT. he reported numerous physical problems. and fatigue. presented with marital problems that had been increasing over the last year. At that time. The goal in IPT is literally to work with the patient quickly to solve his or her interpersonal problems before problematic transference develops and becomes an additional focus of treatment. and typically lengthens the course of treatment. and the therapist may begin discussing the ending of therapy much sooner than with less dependent patients. Furthermore. Despite reassurance from his physicians that he had not developed any complications. he had been given a diagnosis of type 1 diabetes mellitus following numerous consultations for chronic fatigue. he had returned repeatedly to his . a 54-year-old man. the therapist might hypothesize that the patient’s dependency is likely to cause a problem when concluding treatment. Appropriate modifications also would be made with patients who are avoidant or who manifest other personality characteristics. L had no psychiatric history. so that the patient’s needs are more fully met outside of therapy rather than within a dependent or regressive therapeutic relationship. such as headaches. Although he did not endorse any psychiatric symptoms. L.Brief Interpersonal Psychotherapy 125 form the therapist that the patient is likely to 1) relate to others in a similar dependent fashion. both from physicians and from his wife. The continual reassurance-seeking of a hypochondriacal patient would be an excellent example of this kind of behavior. 2) have difficulty in ending relationships with others. L Mr. Case Example: Mr. The therapist also should emphasize to a dependent patient the need to build a more effective social support network. limb pain. This information is then used by the therapist to formulate hypotheses about the patient’s difficulties with others and should lead the therapist to ask questions about how the patient asks others for help. He described being very frustrated with his physicians and their lack of attentiveness to his distress. transference is an extremely important part of IPT but is not addressed directly in therapy. In summary. but his medical history indicated frequent visits to physicians for various physical complaints.

By session 6. and fatigue. the therapist explored what Mr. L quickly responded that the therapy had been very helpful but he was concerned about having to finish because he felt that the therapist was “the only person who really understood my suffering. His typical method of engaging her was to complain of a physical problem and to complain that she did not understand how much pain and suffering he was experiencing. the therapist asked Mr. L was able to recognize that his current communication was alienating his wife and that he needed to ask her more directly for the specific kind of support he wanted. Mr. a contract was established for 12 sessions of acute treatment with IPT. she had responded to this by literally caring for him. he was able to articulate that he really wanted reassurance from both his wife and his doctors. The therapist then suggested that Mr. adding that Mr. In subsequent sessions. dealing with Mr. Mr. Mr. This reassurance from his wife was best delivered as emotional support. L’s immediate response was that he could think of no one.126 The Art and Science of Brief Psychotherapies family doctor with concerns about his vision. L wanted and would tolerate. confirmed this pattern. invited to session 3. she would either ignore his requests or angrily tell him that he needed to “deal with it yourself. He had been encouraged by his family doctor to seek counseling. limb pain. L attend a program for patients with chronic illnesses at the local hospital. L was likely to develop a dependent therapeutic relationship. more recently. to which his wife had responded well. L had always been somewhat dependent but that the diabetes had increased this trait beyond her tolerance. L intended to communicate to his wife and what he really wanted from her. L reported that his initial reaction to the therapist’s suggestion was to feel angry and rejected.” Mrs. L’s dependent traits. L. At the next session. Following an assessment. giving him his shots and monitoring his diet. Mr. Although examining this dependency in longer-term therapy was one option for treatment. Mr. When queried in detail. L was insightful enough to realize that he was “wearing out his welcome” with his doctor and that his wife was getting annoyed with him as well. the therapist brought up the topic during session 7. The therapist recognized that Mr. L’s acute distress and helping him to manage his diabetes more effectively seemed to be goals more in line with what Mr. For a time after the diabetes diagnosis. he had made several attempts at more direct communication. “as if the therapist were sending me out so that he didn’t have to take care of me. L’s communication with Mrs.” He had reluctantly attended the group but found to his surprise that many of the people he had met had experiences similar to his own. L if others in his social network could provide similar support. L was examined in detail. and he found it quite . Anticipating that concluding therapy might be difficult given Mr. particularly if treatment was continued for more than several months. Mr.” Rather than addressing the looming dependency in the context of the therapeutic relationship or addressing the transference implications of this comment. both as a means of extending his social support in general and as a means of identifying others who might understand his experience.

The therapist used this as an example of Mr. Because securely attached individuals are able to communicate . and consequently cannot obtain the physical and psychological care they need. will suffer as a result. and individuals who cannot effectively ask for care. L reported that their relationship was greatly improved. Furthermore.. Mrs. When discussing the conclusion of therapy. Mental health is compromised when people have a fixed attachment style in which they are persistently seeking care but are unable to provide it to others or in which they persistently provide care but are unable to ask for help. which he found quite helpful and supportive. L continued to attend the support group. Mr. individuals seek care from those important to them. Attachment Theory Attachment theory. and Mrs. individuals are less able to deal with crises and are more prone to develop symptoms (Bowlby 1988. L’s typical pattern of response to well-intended offers of help and quickly moved to a discussion of how this pattern played out with his wife. which allow people both to ask for care and to provide care when appropriate. The hallmark of good mental health is the capacity to form flexible attachments. but the relationship between the therapist and patient was not directly addressed. Mr. The therapist chose this intervention using transference to inform the questions about likely problems in relationships outside of therapy. and both Mr. Theoretical Framework IPT is grounded in both attachment theory and interpersonal communication theory. to form and maintain meaningful relationships in which they receive and provide care). rests on the premise that people have an instinctual drive to attach to one another (i. Stuart and Robertson 2003). Bowlby (1988) described three attachment styles that drive interpersonal behavior. L would benefit greatly from continuing his involvement in the group as a means of obtaining social support to deal with his illness. People with secure attachment are able to both give and receive care and are relatively secure that care will be provided when it is needed. although it had seemed as if she were rejecting him. When interpersonal support is insufficient or lacking during times of stress. When crises occur. the therapist continued to emphasize that Mr. they seek emotional proximity. L attended several of the later sessions. L gradually recognized that his wife was attempting to help him by encouraging his independence.e. as described by Bowlby (1988) among others. Interpersonal communication is intrinsic to this process.Brief Interpersonal Psychotherapy 127 useful. too.

severe disruptions of important attachment relationships. Consequently. Avoidant. they typically have good social support networks that are responsive to their needs. will lead to an increased vulnerability to psychiatric symptoms. Rather than eliciting a caregiving response. their unclear or ambivalent requests for help may instead elicit a neutral response or even hostility. People with anxious avoidant attachment typically believe that others will not provide care in any circumstances. they are relatively protected from developing problems when faced with stressors. they have a poor social support network. whereas those more insecurely attached individuals communicate in ways that are indirect or even counterproductive. Thus. A persistent belief that care must be constantly demanded from others. They often lack the capacity to care for others because getting their own attachment needs met outweighs all other concerns. because attachment needs are communicated (well or poorly) within relationships. behave as if they are never quite sure that their attachment needs will be met. such as the death of a significant other. leave these individuals quite prone to difficulties. they avoid becoming close to others. schizoid. with typical dependent behavior (Stuart and Noyes 1999). and antisocial interpersonal behaviors are common. even individuals with secure attachments may have difficulties. attachment theory states that people with less secure attachments are more prone to psychiatric symptoms and interpersonal problems during times of stress. the urgency of the demands is increased in order to ensure that care is provided. such individuals seek care constantly.128 The Art and Science of Brief Psychotherapies their needs effectively and provide care for others as well. along with avoidance of asking for help during crises. As a result. If the stressor is great enough. in contrast. In essence. typically leads insecurely attached individuals to have more difficulty generating social support during times of crisis. leading to an increased vulnerability to illness. Anxious ambivalent individuals usually form insecure relationships. Interpersonal Communication Theory IPT is also based on communication theory. The persistent care-seeking behavior and mal- . Consequently. Poor social connections. or that care will not be provided by others under any circumstances. In addition. which in combination with their difficulties in enlisting help leaves them quite vulnerable to interpersonal stressors. as described by Kiesler and Watkins (1989) and others. Many securely attached individuals are able to communicate their needs effectively. When their demands for care are not met. People with anxious ambivalent attachment.

This attachment style affects the person’s current social support network and the ability to enlist the support of significant others. which compounds the problem.Brief Interpersonal Psychotherapy 129 adaptive communication of an anxiously attached or hypochondriacal individual. for instance. over time. leading to an escalation of demands and further rejection. interpersonal functioning is determined by the severity of current stressors in the context of this social support (Stuart and Robertson 2003). IPT helps people to recognize communication patterns and to make modifications. with a threefold benefit: 1) more effective problem solving occurs as patients directly address conflicts. IPT hypothesizes that psychiatric and interpersonal difficulties result from a combination of interpersonal and biological factors. and 3) these improvements in communication and social support help resolve both interpersonal crises and symptoms (Stuart and Robertson 2003). Summary of Theoretical Framework In summary. and interpersonal sensitivity (detailed later in this chapter. This occurs within the timelimited format of IPT and focuses on here-and-now resolution of symptoms rather than on the transference relationship that develops in therapy. which are reflected in a particular attachment style. interpersonal disputes. tend to exhaust the care provider and ultimately lead to rejection (Stuart and Noyes 1999). and disengaging from relationships. Individuals with a genetic predisposition or biological diathesis will be more likely to become ill when stressed interpersonally. personality traits. Finally. 2) social support improves as patients ask for help in a way that others can respond to more effectively. This further solidifies the insecurely attached individual’s belief that adequate care will not be provided. role transitions. although initially drawing a caregiving response from others. maintaining. . IPT is therefore designed to treat psychiatric symptoms by focusing specifically on patients’ primary interpersonal relationships. symptom resolution is possible when patients repair their disrupted interpersonal relationships and learn new ways to communicate their need for emotional support. see “Problem Areas”). particularly in the problem areas of grief. The insecurely attached individual often does not recognize this pattern or the effect that it has on others. following the biopsychosocial model of psychiatric illness (Stuart and Robertson 2003). The framework and interventions used in IPT are directly linked to attachment and communication theory. On this foundation rest the individual’s temperament. will. The therapist is also concerned with the communication style that the patient uses in initiating. and early life experiences. Although fundamental change in either personality or attachment style is unlikely during short-term treatment.

and treatment conclusion. Clinicians must be active during the course of IPT.130 The Art and Science of Brief Psychotherapies Treatment IPT can be succinctly divided into assessment. There is no need to be concerned about being neutral in order to create an untainted transference reaction. and the patient’s motivation and insight (Stuart and Robertson 2003). the therapist can control the transference reaction to a large degree by assuming the role of a “benevolent expert” and facilitating a positive working alliance throughout the treatment. may be unable to form effective alliances with their therapists in short-term therapy. including the available empirical evidence of efficacy. be restricted to patients with DSM Axis I diagnoses (Stuart and Robertson 2003). Special attention should be paid to patients with personality disorders. schizoid. During each phase. such as narcissistic. A DSM-IV-TR diagnosis should be made because IPT appears to be well suited to patients with mood (empirically validated) and anxiety disorders. The therapist also should be supportive. Assessment An assessment is conducted to determine when IPT should be used and to whom it should be applied. may require more intensive therapy than can be provided in an IPT format. maintaining the focus of therapy and keeping the patient on task. initial sessions. the attachment and communication style of the patient. However. The therapist also should make every effort to convey a sense of hope to patients and reinforce their gains. whereas those with severe Cluster B disorders. IPT should not. or schizotypal personality disorder. the “blank screen” approach should be abandoned in favor of a stance that is empathic and strongly encouraging. It is quite suitable for patients with a variety of interpersonal problems such as work conflicts or marital issues. patients without major psychiatric illness often have greater interpersonal resources and better social support networks. histrionic. each of which is designed to foster the therapeutic goals of the patient. many patients with depression or anxiety superimposed on a personality disorder may benefit from short-term IPT if the focus is on depression or anxiety rather than on personality change. In fact. the clinician has a well-defined set of tasks to accomplish. borderline. They present . The therapist should be guided by several factors. however. in fact. or antisocial personality disorder. The stance taken by the therapist supports the therapeutic tasks and techniques. such as paranoid. intermediate sessions. Those with Cluster A disorders.

or who are needed but tend to be unreliable.Brief Interpersonal Psychotherapy 131 with circumscribed and specific interpersonal problems. Those with anxious avoidant styles of attachment may have difficulty trusting or relating to the therapist. taking great care to convey a sense of understanding and empathy to the patient. For example. Consequently. before moving into more formal IPT work. Individuals with more anxious ambivalent attachments usually can quickly form relationships with their clinicians but often have great difficulty with the conclusion of treatment—a particular problem in time-limited therapy. ill. or otherwise in need of care are particularly helpful. When working with avoidant patients. The therapist is essentially developing hypotheses regarding the patient’s model of relationships—that is. Unfortunately. Soliciting feedback from the patient about the intensity of treatment. the astute therapist may modify his or her approach by emphasizing the time-limited nature of the treatment and by discussing the conclusion process earlier. The patient also should be queried about his or her typical responses when asked to assist others. The way in which patients communicate their needs to others has profound . as in other psychotherapies. consisting of the patient’s perception of his or her style of relating to others. Those patients with more secure attachment styles are usually able to form a working relationship with the therapist and. Questions about what the patient does when stressed. and an evaluation of the patient’s past and current relationships. are also more likely to be able to draw on their social support system effectively. Significant others also may be included in sessions more frequently. the old saying about “the rich getting richer” holds true. The therapist should use the assessment to forecast and plan for problems that may arise during therapy. whether the patient tends to see the world as full of people who can generally be trusted. The assessment should include an evaluation of the patient’s attachment style (Stuart and Robertson 2003). who should be avoided. is another tactic that may improve the therapeutic alliance with avoidant individuals. because patients with anxious ambivalent attachment styles may have difficulty in ending relationships. the therapist should plan to spend several sessions completing an assessment. to ensure that dependency on the therapist does not become problematic. particularly considering less frequent appointments. The therapist should assess the patient’s communication style. in IPT. The patient’s attachment style has direct effects on his or her ability to develop a therapeutic alliance with the therapist and the likelihood that treatment will be beneficial. and they are frequently superb candidates for IPT. because of their relatively healthy relationships outside of therapy. the therapist may need to spend several of the initial sessions working on developing a productive therapeutic alliance.

The selection of patients can best be understood to be on a spectrum. and the determination that the patient is suitable. Therapists who are overly directive may have difficulty with avoidant patients. should IPT formally begin. There are no formal contraindications to IPT. also have idiosyncratic styles of attachment and communication. 2) a relatively secure attachment style. 3) the ability to relate a coherent narrative. but there are clearly patients who might benefit more from treatments other than IPT. attachment style. like patients. Only after the assessment. and communication patterns should be assessed. the therapist has four specific tasks: . should determine the patient’s suitability for IPT. Other desirable characteristics for IPT include 1) a specific interpersonal focus. particularly with regard to being able to accurately represent the other person’s point of view. social transition. The old adage “know thyself” cannot be overemphasized. for therapists. In summary. patients who have characteristics that render them good candidates for any of the time-limited therapies will be good candidates for IPT.132 The Art and Science of Brief Psychotherapies implications for the therapeutic process. These include motivation. or interpersonal conflict. and high-level defense mechanisms in the context of sufficient ego functioning. In general. such as a loss. good insight. average or better intelligence. the initial assessment. and 4) a good social support system. and should direct the therapist to modify his or her therapeutic approach so that these problems are minimized. which often takes several sessions to complete. with highly suitable patients on one end and those who may be less suitable on the other. the therapist should assess the match between himself or herself and the patient. Patients who are able to relate a coherent and detailed story are likely to be able to provide the narrative information necessary to work productively in IPT. Insight also can be judged by noting the way in which the patient describes an interaction and the degree to which he or she presents a balanced picture. Initial Sessions During the initial sessions of IPT (usually the first one or two meetings following the general assessment). for example. The patient’s psychiatric status. The assessment should assist the therapist in anticipating problems in therapy. The therapist should directly ask the patient for examples or vignettes in which a conflict with a significant other occurred. such as resistance or dependency. Finally. Therapists who find it difficult to terminate treatment may encounter problems with dependent patients (Stuart and Robertson 2003). along with the ability to relate specific dialogue from interpersonal interactions. as well as for the likelihood that the patient will improve.

the contract is particularly important as a point of reference for both patient and therapist. 2) to work collaboratively with the patient to determine which problem areas will be the focus of treatment. role transitions. and because the IPT practitioner avoids directly addressing the transferential elements of therapy. problems in the relationship. Attention should be drawn to the interpersonal orientation of the therapy. and other issues that might lead to problems in the therapy should also be tackled in the initial stages of treatment. and the expectations that the patient has about the relationship. 1984) consists of a brief description of the important people in the patient’s life and for each individual includes information about the amount and quality of contact. As in all psychotherapies.Brief Interpersonal Psychotherapy 133 1) to conduct an interpersonal inventory. The inventory helps the patient (and therapist) determine which relationships are appropriate to work on. the relationships that are noted to be problematic and subsequently become treatment foci will be revisited in detail later. interpersonal disputes. symptomatic relief is expected to follow. Once the inventory is complete. frequency. establishing a therapeutic framework—a contract—for the treatment is an essential part of IPT. and 4) to develop a treatment contract with the patient. These descriptions are not intended to be exhaustive. The therapist also should explain the rationale for IPT in concrete terms. and duration of sessions • The clinical foci of treatment: the problem areas that have been agreed on by the patient and therapist . The therapist should frame the patient’s problem as interpersonal and should give specific examples of the way in which the problem fits into one of the four problem areas: grief or loss. 3) to present to the patient a rationale for the use of IPT. The contract should specifically address • The number (generally 12–20). because IPT is time limited. In fact. and interpersonal sensitivity. The interpersonal inventory (Klerman et al. The time limit must be specifically negotiated with the patient. and the patient should be instructed that he or she will be expected to discuss interpersonal relationships. It also aids the therapist in gathering further information about the patient’s attachment and communication patterns (Stuart and Robertson 2003). the patient and clinician should mutually identify one or two problem relationships on which to focus. Furthermore. the patient should be explicitly told that the goal of therapy is to modify communication patterns and/or expectations about relationships and that as these changes occur.

the therapist can note to the patient that both had initially agreed on certain guidelines for therapy (such as meeting at the scheduled time rather than 15 minutes later) and that the patient. emergencies. In IPT. contact out of hours. the patient and therapist work together to address the interpersonal problems identified during the assessment. lateness. this is in direct contrast to traditional transference-based therapy. particularly the need for the patient to take responsibility for working on his or her communication between sessions • Contingency planning: addressing issues such as missed sessions. the therapist can hypothesize that the same behavior also occurs in the patient’s relationships outside of therapy. by failing to meet his or her responsibility. For example. in which the therapist examines the behavior in the context of the therapeutic relationship. work on these issues proceeds in the following order: 1) identification of a specific interpersonal problem. These may vary from simple matters such as lateness or delayed fee payments to more significant problems such as inappropriate behavior in the sessions or other disruptive interactions. is in essence keeping himself or herself from benefiting maximally from the treatment. As we have seen. the therapist can use them to examine similar problems outside of the treatment. The therapist would then ask the patient about similar difficulties he or she might have with others. rather than addressing the transferential implications of such behaviors.134 The Art and Science of Brief Psychotherapies • The roles of the patient and therapist. the contract must serve as a rock-solid reference for both patient and therapist. 2) detailed ex- . When contract violations occur. Because of the injunction in IPT against discussing the transference relationship directly. if a patient delays attempting changes in communication. or illness • Acceptable conduct in the sessions. and behavioral expectations such as those in regard to substance use and aggressive or inappropriate behavior Despite the establishment of an explicit contract. Intermediate Sessions During the intermediate sessions of IPT. The therapist would then proceed to ask questions about similar behavior outside of the therapeutic relationship. In general. “violations” may occur. It is important that the IPT therapist initially view these problems as interpersonal communications because they provide valuable information about both the patient’s experience of the therapeutic relationship and his or her communication problems outside of therapy.

with a movement toward other social support. Case Example of Change in Communication: Ms. including whether it is a problem in communication in the relationship or a matter of unrealistic expectations about the relationship. Ms. and because she was breast-feeding. She had no psychiatric history. he had largely quit helping. She described a lack of energy. she was quite critical of him for not being as careful and thorough as she thought he should have been. For instance. poor sleep. and a feeling of being overwhelmed. behavior. After obtaining information about her general social support. which she felt was due in large part to conflicts with her husband. 3) collaborative brainstorming to identify possible solutions to the problem or to identify ways in which the patient may be able to change his or her communication with significant others. A change in expectations. it became clear that Ms. such as a change in location or in employment. presented with complaints of fatigue at 4 months postpartum. she often felt it was not adequate and berated him for his efforts. She was irritable and had a short temper. In fact. it is change in communication. M was actually being quite critical of her husband. low self-esteem. a change in communication to a style that is more direct may be of help with a patient who is experiencing a dispute. the end point of therapy is not simply insight. however. with positive encouragement for the changes made and discussion of refinements to the solution to be carried out by the patient (Stuart and Robertson 2003). Rather than seeing this as his attempt to be helpful and giving him positive feedback. who she felt had not been helping with the care of their baby. Ms. As a result. The last phase of the problem-solving approach is that the therapist and patient monitor the consequences of the attempted solution and make modifications as needed. When she was asked to describe specific interactions and her communication in detail. In IPT. M had come home late from work to find her husband giving their son a bath. and social support that leads to symptom resolution. a 31-year-old woman. She narrated a specific example: Ms. After discussing several such instances. Various solutions can be considered for the problems with which patients present. and 5) review of the patient’s attempted solution and its results. A change in circumstances. 4) implementation of the proposed solution (typically between sessions). she had no desire to take medications. it was discouraging him from doing so and was leading her to feel in- . may be of benefit for a patient moving through a role transition.Brief Interpersonal Psychotherapy 135 ploration of the patient’s perception of the problem. M Ms. is also a viable option. M and her therapist agreed to work on her relationship with her husband. M was able to see that her style of communication was not encouraging her husband to help her. M. when he made attempts to help.

N at communicating his feelings. N talked with his father about his disappointment that he had not attended the graduation and his wish that his father would recognize what Mr. N’s father was a prominent lawyer and had expressed a great deal of disappointment that Mr. N’s expectations of his father. Mr. he was likely to be self-critical and downplay his achievements. he liked and needed more positive feedback from others. As a result. Case Example of Change in Expectations: Mr. had recently graduated from medical school. Mr. . a 28-year-old man. indicated that he felt more appreciated and began to do more of the child care and housework. N to literally grieve the loss of the father he wished to have. Both reported an improvement in their relationship. N had gone to medical school. N and the therapist spent a great deal of time discussing Mr.” Mr. Mr. N that “at least you can go to law school now that you’ve finished medicine. Mr. N reported several good relationships. Mr. however. M also reported that her fatigue and irritability were greatly improved. showed a very conflicted relationship with his father. N reported that he felt better after revealing the conflictual relationship with his father to others for the first time and that it helped a great deal that they had been sympathetic and responsive. His fiancée had even thrown him a belated graduation party. The interpersonal inventory. Once she recognized this pattern. who was invited to several of the later sessions. N began to recognize that it was quite likely that his father would never be able to respond in the way in which he wanted and was likely to continue to be distant despite Mr. N’s father seemed incapable of responding to his son’s requests and continued to be somewhat distant and critical. Despite several valiant attempts on the part of Mr. Mr. N also recognized that because of his interactions with his father. which he enjoyed. He was seeking help for feelings of fatigue and disappointment. N described him as very demanding and noted that his father rarely appreciated any of his accomplishments. Mr. therapy shifted to a discussion about Mr. His father had refused to attend the graduation and commented to Mr. and some close relationships with medical school colleagues. Time was spent helping Mr. he felt neither pleasure about his graduation nor any sense that he had accomplished much in his life. N’s fiancée and several of his close friends were able to discuss this with him and were very supportive. Given the history and consistency of his father’s interactions with him. In contrast to his father. with the goal of helping him to communicate this anger more directly and to be more direct in asking for the support he wanted. After several sessions. N’s improved communication with him. N’s anger at his father. N. Nonetheless.136 The Art and Science of Brief Psychotherapies creasingly frustrated. Her husband. Mr. He reported that although he intellectually recognized that he had accomplished a great deal and had a bright future. N had accomplished. Mr. she was able to make some changes and was more appreciative of his help. N Mr. including a supportive one with his fiancée. and Ms.

It is also often useful if the therapist highlights the consequences of not changing and directly addresses the patient’s ambivalence.Brief Interpersonal Psychotherapy 137 When concluding treatment.g. The issue is rarely that the patient does not know or has not been told what to do to solve the problem but rather that the patient has not been able to accept or implement the proposed solution. Getting married. . and attaining other life goals might be times when Mr. Within the IPT model. Implementation difficulties may be dealt with similarly in a direct fashion when they first appear. and 2) those that involve implementation of changes.. Consequently. N would be welcome to return for another course of therapy. Mr. N had made a great deal of improvement. Second. the therapist should assist the patient in exploring what made the implementation difficult. It is rare that patients will improve with nothing more than good advice from the therapist. the therapist pointed out that even though Mr. much of the therapist’s work in the intermediate sessions of IPT involves dealing with the patient’s resistance to the therapeutic process and his or her ambivalence regarding change. he or she can refer to the agreement reached in the first sessions of IPT (e. N and his therapist agreed that should such problems arise in the future. Resistances can be divided into two categories for the purposes of IPT interventions: 1) those that are contractual. Furthermore. he might encounter other difficult life transitions. contractual problems should first be dealt with directly by stating to the patient that he or she will not get the full benefit of therapy if he or she misses some appointments or misses some of the time allocated to each session. The therapist should remind the patient that a time limit to therapy exists and that the benefit of therapy will be maximized if changes are attempted. such as missed appointments or being late for appointments. having his own children. Both Mr. in addition to the various techniques described later in this chapter. it is in fact often difficult. Because the therapist has already negotiated a detailed treatment contract with the patient. that the patient has agreed to treatment lasting 12 weeks). Dealing With Resistances Although this approach sounds rather simple. such as the patient being unwilling to attempt agreed-on solutions or “forgetting” to take steps to change his or her relationships (Stuart and Robertson 2003). It is useful for clinicians to remind themselves that most patients have already had their fill of “good advice” by the time they arrive at the therapist’s office. N’s feelings about his father might resurface. The therapist should note that each missed appointment reduces the time available for treatment and reduces the patient’s chances for recovery. the death of his father at some point might be very difficult.

it is helpful to negotiate the number of therapy sessions rather than a specified number of weeks of therapy. Several specific techniques may facilitate the conclusion of therapy. Addressing the issue in this way often helps the patient appreciate the ways in which his or her pattern of communication provokes unproductive responses in others. reinforce the changes that they have made. but they often derive additional benefit from extending session intervals to biweekly or monthly once their functioning has improved. the patient and therapist may choose to meet biweekly or even monthly toward the end of treatment. and has the capability to function independently. In these cases. it is often helpful to ask the patient what kind of response he or she is expecting from the therapist and others in the face of this unwillingness to change.138 The Art and Science of Brief Psychotherapies Many patients will respond to these direct interventions. has made changes. all of which facilitate better and more stable functioning. As acute treatment ends. six to eight weekly sessions may be sufficient to resolve their acute problems. For more highly functioning patients. The therapist is still available in the background should a future emergency arise. Completion of Acute Treatment The best clinical practice in IPT is usually to extend the interval between sessions once the patient is in the recovery stage of acute treatment (Stuart and Robertson 2003). however. and develop more self-confidence while remaining in a supportive relationship. After having met weekly for most of treatment. The therapist may be one of the first people who has taken an in- . Therefore. patients persist in their resistance despite these active steps by the therapist. Because the primary goal of IPT is symptom relief and improvement in interpersonal functioning. the therapist should make clear that the patient has improved. but the expectation is that the patient will function independently and do so quite capably. This gives them the opportunity to further practice communication skills. It is important to acknowledge a sense of loss that a patient may experience. The idea is to help the patient appreciate that he or she has resources and skills to manage problems and to squarely attribute therapeutic gain to the patient. Occasionally. however. Rather than dwell on the patient–therapist relationship. the specific aim at the time of treatment conclusion is to foster the patient’s independent functioning and sense of competence. the IPT practitioner should then move to other problematic relationships to help the patient appreciate similar communication styles and the responses he or she may be provoking from others. particularly if they are conveyed with a sense of understanding by the therapist.

the conclusion of acute treatment with IPT does not signify the end of the therapeutic relationship (Stuart and Robertson 2003). The conflict between maintaining the therapeutic contract and extending sessions can be resolved simply by renegotiating a new contract with the patient (Stuart and Robertson 2003). concluding acute treatment with the understanding that the patient will contact the therapist should problems recur. 1990). Decisions about how to structure future treatment must rely on clinical judgment. In fact. A specific contract should be established with the patient for whichever option is chosen. therapists have many patients. and therapists often underestimate the effect of concluding therapy. in which “termination” constitutes a complete severing of the therapeutic relationship. Unlike the end of treatment under the traditional psychoanalytic model. The therapist should reassure the patient that it is normal to feel a sense of loss. and provision is specifically made for these.Brief Interpersonal Psychotherapy 139 terest in the patient. Several alternatives exist for the provision of this maintenance treatment. or planning to have the patient contact another provider in the future if the therapist is not available. After all. whereas patients have only one therapist. in IPT it is often agreed that the patient and therapist will have therapeutic contacts in the future. Not only are many of the major psychiatric disorders (such as depression and anxiety disorders) relapsing and remitting in nature. but also clear evidence indicates that provision of IPT as a maintenance treatment after recovery from depression is helpful in preventing relapse (E. if extending the therapy beyond the number of sessions initially agreed on is clearly in the patient’s best interest. Also. The . The success of therapy is also dependent on the patient’s belief that the therapist is absolutely committed to helping the patient. Although providing intermittent maintenance treatment with IPT may potentially lead to transference problems. Frank et al. Consequently. It signifies the effort that the patient has put into the work and into building a relationship with the therapist. Options include specifically scheduling maintenance sessions at monthly or greater intervals. The IPT practitioner should always discuss maintenance treatment with his or her patient (Stuart and Robertson 2003). Maintenance Treatment Acute treatment with IPT comes to an end as specified by the therapeutic contract. then it should be extended. it is normal for patients to fear that they will not be able to maintain their gains without the therapist’s ongoing support. the development of problematic transference and the drive to focus on it as a necessary element of therapy is a function of three things (Stuart and Robertson 2003).

theory. although not sufficient for . genuineness. like a general practitioner. IPT incorporates several traditional psychotherapeutic methods.140 The Art and Science of Brief Psychotherapies first is the patient himself or herself: the more maladaptive the patient’s attachment style and communications. Third. in the same fashion as the general practitioner. such as exploration. More important than any techniques. In the interim. the therapeutic relationship is not terminated. empathy. at which time another time-limited course of treatment is undertaken. and conveying unconditional positive regard. Warmth. Second. it is the focus on extratherapeutic interpersonal relationships rather than any particular intervention that characterizes the therapy. Clinical experience. to provide “health maintenance” sessions periodically. Techniques and the Therapeutic Process Although several techniques (described later in this section) are specific to IPT. in the service of helping the patient to modify his or her interpersonal relationships. weekly vs. however. Indeed. five times per week). Once this occurs. All of them are used. the therapist makes himself or herself available to the patient should another crisis occur. the more likely transference is to become a focus of therapy.. Not surprisingly. however. IPT can be understood as following a “family practice” or “general practitioner” model of care. and empirical evidence all make clear that IPT should be conceptualized as a two-phase treatment. no techniques are actually forbidden in IPT. given its psychodynamic roots. is the establishment of a productive therapeutic alliance. In essence. clarification. the therapist may choose. in which a more intense acute phase of treatment focuses on resolution of immediate symptoms and a subsequent maintenance phase follows with the intent of preventing relapse and maintaining productive interpersonal functioning (Stuart and Robertson 2003). while giving great benefit to the patient (Stuart and Robertson 2003). however. the more likely transference will become problematic and need to be addressed. the duration of treatment is correlated with the development of problematic transference: the longer treatment continues. and even some directive techniques. transference becomes a greater therapeutic issue. the intensity of treatment is positively correlated with the intensity of the transference: as therapy sessions are held more frequently (e.g. Monthly or bimonthly follow-up sessions consequently confer little risk of precipitating transference problems. in which short-term treatment for an acute problem or stressor is provided until the problem is resolved (Stuart and Robertson 2003).

Interpersonal incidents are descriptions by the patient of specific interactions with his or her significant other. Nonspecific Techniques Nonspecific techniques are those that are common to most psychotherapies. convey that understanding to the patient. Rogers 1957). Techniques should not be used simply because they are included in a manualized protocol. If the patient does not perceive that the therapist is truly committed to doing this. and provide information about the genesis of the patient’s problems and potential solutions to them. all IPT interventions should be therapeutic—the ultimate value of an intervention is the degree to which it helps the patient. the benefit to the patient should guide the interventions used in treatment. These techniques play a crucial role in IPT because they serve to help the therapist understand the patient’s experience. and assigning homework can be used judiciously as well in the service of facilitating change. an obstacle that no amount of technical expertise can overcome. The therapist’s task is to help the patient to communicate more clearly what he or she wants from significant others and to convey his or her needs more effectively. Communication analysis requires that the therapist elicit information from the patient about important interpersonal incidents (Stuart and Robertson 2003). will not feel valued as an individual. the patient will not disclose information as readily. giving directives. are all necessary for change in IPT (J. Patients often assume that their communication is clear. Furthermore. Frank 1971. If the identified dispute results in a pattern of fighting between spouses. and will not develop a meaningful relationship with the therapist. Without a productive alliance. Specific techniques are of no benefit if the patient is not present in the therapy. In IPT. the patient will flee therapy. the therapist . all of the techniques that are used should focus primarily on the patient’s interpersonal relationships and also should facilitate the therapeutic alliance. Examples are the use of open-ended questions and clarifications and the expression of empathy by the therapist. The primary goal of the IPT practitioner should be to understand the patient.Brief Interpersonal Psychotherapy 141 change in IPT. Working to understand the patient should always take precedence over any technical interventions. Techniques such as brainstorming with the patient. when in fact it may not be understood at all by the people to whom it is directed. Communication Analysis and Interpersonal Incidents The analysis of the patient’s communication patterns is one of the primary techniques used in IPT.

how her husband responded. how she responded in turn. For instance. Because this is not usually how patients spontaneously present information about their conflicts. The re-creation should include a detailed description of what the patient said to begin the interaction. The patient may. slamming doors. What is more likely is that the patient’s husband may indeed be insensitive.” The therapist should direct the patient to describe the communication in detail. Special note should be made of the end of the interaction because many conflicts may carry over to the next day or may be brought up again in subsequent disagreements. also be unwittingly ignoring important communications.” although containing a grain of truth. a patient may say that her husband “never listens to her. although she is intending otherwise. come across as critical or uncaring or may simply be trying to communicate at a time when her words will not be well received. The goal is to use this step-by-step report to understand the way in which the patient conveys . almost always represent only one side of the story. the therapist must actively direct the patient to produce this material. The purpose of discussing an interpersonal incident is twofold: 1) to provide information about the miscommunication that is occurring between the parties and 2) to provide insight to the patient about the unrealistic view that the problem is intractable. The therapist should ask about not only the verbal interactions but also the nonverbal communications that occurred. The therapy proceeds from a general problem statement on the part of the patient to a specific re-creation of the dialogue between the patient and her spouse. The patient should be directed to describe his or her affective reactions and both verbal and nonverbal responses and to describe observations of his or her spouse’s nonverbal behavior. and leaving the situation in the middle of an interaction. but some of his nonresponsiveness is a result of the reciprocal communication style of the couple. a specific interaction between herself and her husband. leaving the therapist with little information about the specific communication that occurred.142 The Art and Science of Brief Psychotherapies might ask the patient to “describe the last time you and your spouse got into a fight” or to “describe one of the more recent big fights you had with your spouse. what she understood him to say. such as using silence in a hostile fashion.” General statements such as “My husband never listens to me. in as much detail as possible. She may. as may her husband. A typical patient will describe an interaction with a significant other in very general terms. re-creating the dialogue as accurately as possible. and so forth. The problem is framed as a communication difficulty within the relationship rather than blaming either individual. the therapist’s goal in eliciting interpersonal incidents is to have the patient re-create. Therefore.

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her attachment needs, acting on the hypothesis that she is communicating in a way that is being misunderstood, and she is therefore not being responded to as she would like.

Case Example: Ms. O
Ms. O, a 36-year-old woman, complained of depression that she attributed to constant conflicts with her husband of 10 years. She described him as uninterested in her and stated that he “never appreciates all the work that I do.” She described that despite her full-time job, her husband expected her to do all of the housework and never offered to be of any help. Her depressive symptoms and decrease in functioning apparently had gotten his attention, however, because she reported that they had recently had a big fight over the fact that the housework was left undone. The following dialogue is from session 3: Ms. O: Last week was the same as always—he ignored me all week. I don’t think he’ll ever change. (Note the implication from Ms. O that the conflict between her and her husband is intractable.) Therapist: The way you describe the problem with your husband, it sounds as if you don’t think there will ever be any improvement. Let’s take a closer look at one of your fights. Tell me about the last time you and your husband got into a fight because you felt he ignored you. Ms. O: Last night was typical. After supper, he went into the living room and turned on the TV. I was feeling depressed and angry, so I turned off the TV so he’d pay attention to me. Therapist: What happened after that? Ms. O: He looked at me for a minute, then ignored me again by picking up the newspaper. Therapist: How did you respond to that? Ms. O: Like anyone would! I said, “If you’re going to treat me like that, I’m leaving!” Therapist: You seem really angry right now as you’re talking about that incident. Ms. O: I’m furious! He always does that to me! Therapist: It sounds like you certainly conveyed your feelings to him through your actions. I wonder, though, if your husband understood that your original intent was to get him to pay attention to you: to acknowledge that you are important to him. How does he usually respond to you when you’re angry? Ms. O: Well, he usually just withdraws. He grew up in a family that didn’t communicate much, and he doesn’t like conflict. Therapist: So when you express anger to him, especially through your actions, he usually withdraws or ignores you. It seems

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Ms. O and her therapist went on to discuss the likely effect of her communications to her husband. Mr. O acknowledged his withdrawal response during a conjoint session several weeks later. As Ms. O made attempts to communicate her needs more directly to her husband, and especially as she stopped her threatening comments, she found that he was more willing to be supportive both emotionally and physically.

Use of Affect
The more the patient is affectively involved in therapy, the more likely the patient will be motivated to change his or her behavior or communication style. Consequently, one of the most important tasks for the IPT practitioner is to attend to the patient’s affective state. Of particular importance are those moments in which the patient’s observed affective state and his or her subjectively reported affect are incongruent. Examining this inconsistency in affect can often lead to breakthroughs in therapy. Affect can be divided into that experienced during therapy (process affect) and that reported by the patient to have occurred at some time in the past (content affect) (Stuart and Robertson 2003). Content affect is the predominant affect experienced at the time of the event. For instance, a patient might describe feeling “numb” at the time of the death and funeral of a significant other. Process affect, on the other hand, is the affect experienced by the patient as he or she is describing to the therapist the events surrounding the loss. The same patient, for example, might describe a “numb” feeling at the time of the funeral but while describing the event to the therapist might be in tears and feeling sadness, or perhaps anger. When met with this incongruence in affect, the therapist can focus directly on the discrepancy between content and process affect.

Case Example: Mr. P
Mr. P, a 35-year-old man, presented with symptoms of depression 6 months after the death of his father, who had died unexpectedly from pancreatic cancer. Mr. P’s father had been a salesman who was frequently away on business trips and appeared to the therapist to be someone who prioritized his work over his family. Nonetheless, during the first few sessions, Mr. P consistently described his father as loving, caring, and an excellent father. Mr. P described having no feelings of sadness about his father’s death and felt very guilty that he had none of what he considered to be “socially appropriate” feelings. The following dialogue occurred in the fourth session:

Brief Interpersonal Psychotherapy Therapist: Tell me more about your experiences at your father’s funeral. Mr. P: It was a warm, pleasant day—I remember thinking that I would rather be outside working in the yard than going to the funeral. I just…I just felt numb—nothing, the whole time. Therapist [noting the patient’s sad affect]: Tell me what you feel right now as you’re describing the funeral to me. (Note the therapist distinguishing between the process and the content affect.) Mr. P [becoming tearful]: I’m not sure.…I guess I feel sad but not quite like I expected. I guess I also feel rather angry at my dad. You know, he wasn’t really around all that much. I remember when I was about 14 years old and had a big baseball game, and I begged him to come.…He said that he was too busy, and I remember being angry with him all day after the game.

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Mr. P went on to describe several other incidents with his father. During therapy, he developed a much more balanced and realistic picture of his father, including both his positive attributes and his shortcomings.

Use of Transference
Given the interpersonal and psychodynamic foundation on which IPT rests, transference can and does play an extremely important role in the therapy. By observing the developing transference, the therapist can begin to develop hypotheses about the way that the patient interacts with others outside of the therapeutic relationship, because the way in which a patient relates to the therapist is a reflection of the way he or she relates to others. Thus, the transference recognized by the clinician provides a means of understanding other relationships in the patient’s interpersonal sphere.

Case Example: Mr. Q
Mr. Q, a 40-year-old man, had been referred by the human relations officer at his company for continuing conflicts with supervisors. Although his sales work was excellent, the human relations officer reported that Mr. Q often got into arguments with his supervisors and peers and was on the verge of losing his job as a result. Mr. Q reported that the problem was with the company, which “obviously doesn’t appreciate that good salesmen need to be encouraged to operate independently and not be constantly interfered with.” He was quite clear that he did not see himself as the problem; it was the attitude of others that was at issue. He had agreed to come to treatment only because he realized that if he did not comply, he might lose his job.

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Recognizing that the therapeutic alliance was tenuous, the therapist spent the first several sessions listening patiently to Mr. Q’s side of the story, expressing empathy about the difficult situation that Mr. Q was in. Furthermore, the therapist assured Mr. Q that he was working only for Mr. Q’s benefit, not for the company, and that confidentiality would be completely maintained. As Mr. Q began to develop more trust in the therapist, he began to reveal more about how difficult it had been at work. Although he had done well with sales, he did not feel that he had any close friends and felt that he had little support. He stated that he wanted to have colleagues at work with whom he could talk about the stress of his job and to whom he could go for new ideas or advice. He did recognize that he had trouble asking for help, largely because he did not trust others and because he believed that they would have little to offer. A turning point in therapy came at session 6, for which the therapist was about 15 minutes late. After entering the therapist’s office, Mr. Q began berating the therapist about his lack of respect because of his lateness. Mr. Q said that he “had lots of important things to do, and the therapist obviously didn’t realize that Mr. Q’s time was valuable: time was money.” Rather than deal with the transferential elements directly, the therapist responded by doing two things. First, he chose to honestly tell Mr. Q why he had been late: he had been called to his child’s school earlier in the morning because his son’s arm had been broken, and his son had been admitted to the emergency department. This revelation would have been contraindicated in a more transferentially based therapy, but in IPT, it had the effect of allowing the therapist to give direct feedback to Mr. Q about the therapist’s reaction to Mr. Q’s angry statements. Second, the therapist stated directly that Mr. Q’s immediate assumption that he had been wronged had initially made the therapist quite angry. The therapist stated that he had wanted to ask Mr. Q to leave and simply stop seeing him for therapy. However, the therapist went on to state that after thinking about it further, he realized that his reaction had helped him to understand how others at Mr. Q’s workplace might be feeling when Mr. Q got angry with them. Mr. Q somewhat sheepishly apologized for his angry statements, which the therapist graciously acknowledged. The therapist, using the patient–therapist interaction that had occurred as a basis for his next set of questions, began to ask Mr. Q in more detail about work interactions in which he had gotten angry and during which others had gotten angry in return. The in-session interaction both informed the questions that were asked about Mr. Q’s extratherapy relationships and provided the impetus for Mr. Q to begin to develop a different perspective on how others perceived him. Over the next several sessions, Mr. Q and the therapist developed the hypothesis that Mr. Q’s expressions of anger, although at times warranted, usually had the effect of causing others to respond by getting angry in return. His impulsive anger was keeping him from developing the close relationships with others that he desired. By the end of therapy, Mr. Q reported that he was getting along better with others at work. His supervisor also endorsed these changes. Mr. Q

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continued to have some difficulty with his anger, but in contrast to his behavior pretherapy, he usually felt able to “control” his anger on most occasions by stopping to think about the reaction that he was likely to get from others.

Problem Areas
IPT focuses on four specific problem areas that reflect the interpersonal nature of the treatment: grief, interpersonal disputes, role transitions, and interpersonal sensitivity. Psychosocial stressors from any of the problem areas, when combined with an attachment disruption in the context of poor social support, can lead to interpersonal problems or psychiatric syndromes (Stuart and Robertson 2003).

Grief and Loss
It is useful to formulate many types of losses as grief issues. In addition to the death of a significant other, loss of physical health, divorce, and loss of employment are examples of interpersonal stressors that might be experienced by the patient as grief (Stuart and Robertson 2003). In general, it is usually best for the therapist to place the patient’s problems within the problem area that makes the most intuitive sense to the patient. Moreover, grief need not be considered as “normal” or “abnormal”; it is the task of the IPT practitioner to attempt to understand the patient’s experience, not pathologize it. Once a grief issue is established as a focus of treatment, the therapist’s tasks are to facilitate the patient’s mourning process and to assist the patient in developing new interpersonal relationships or in modifying his or her existing relationships so as to obtain increased social support. New or existing relationships cannot replace the lost relationship, but the patient can reallocate his or her energies and interpersonal resources over time. Several strategies are useful in dealing with grief issues. Primary among these is the elicitation of feelings from the patient, which may be facilitated by discussing the loss and the circumstances surrounding it, both of which serve to help the patient to realistically reconstruct the relationship. The use of process and content affect may be quite useful during this type of discussion. Grief issues commonly involve layers of conflicted feelings surrounding the lost person, and assisting the patient to develop a three-dimensional picture of the lost person, including a realistic assessment of the person’s good and bad characteristics, is a necessary process in the resolution of the grief. Often the patient will initially describe the

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lost person as “all good” or “all bad” and be unaware that this idealization (or devaluation) covers other contradictory feelings that may be difficult for the patient to accept. The development of a balanced view of the lost individual greatly facilitates the mourning process. This same process can be used for other losses as well: the loss of a job, a divorce, or loss of physical functioning. In such instances, the patient also will need to grieve the loss and to move toward establishing new social supports. Encouraging patients to develop a more realistic view of their loss may be of help as well.

Interpersonal Disputes
The first step in dealing with interpersonal disputes is to identify the stage of the conflict and to determine whether both parties are actively working to solve the problem, have reached an impasse, or have reached a point at which dissolution of the relationship is inevitable (Klerman et al. 1984). It is important to keep in mind that successful treatment does not necessarily require that the relationship be repaired. The important point is that the patient makes an active and informed decision about the relationship. One of the primary goals with interpersonal disputes is to help patients to modify their patterns of communication. Particularly in relationships of longer duration, patients often become locked into patterns of communication with their significant others that result in misunderstanding or in cycles of escalating affect. The therapist can show the patient how to communicate his or her needs more clearly and in a way that is more likely to gain what the patient is requesting rather than provoke hostile responses. The therapist should model direct communication to the patient and may engage the patient in role-playing to reinforce the new communication. Although IPT is generally an individual therapy, inviting a significant other to therapy for several conjoint sessions can be invaluable because the therapist can observe the communication in vivo and can begin to help the couple to make changes in the way in which they interact.

Role Transitions
The problem area of role transitions encompasses a huge number of possible life changes. Included are life-cycle changes such as adolescence, childbirth, and a decline in physical functioning and social transitions such as marriage, divorce, change in job status, and retirement. Typical problems include sadness at the loss of an old familiar role, as well as poor adaptation to or rejection of the new role. Role transitions often include loss of important social supports and attachments and may include a

often using some of the techniques described for dealing with grief issues. may be one of the only relationships in which the patient is engaged. Relationships with family members. Consequently. if any. . even though they may be quite disrupted. Interpersonal Sensitivity Some patients may have problems with poor interpersonal functioning because of personality traits. the therapist should use the problem areas primarily to maintain focus on one or two interpersonal problems. Summary of Interpersonal Problem Areas These categories are very helpful as a means of focusing the patient on specific interpersonal problems. The therapy relationship also may take on greater importance with these patients because it. too. the therapist often must be active in assisting the patient in getting involved in appropriate social groups or activities in the community. which includes helping the patient to experience grief over the loss. interpersonal relationships to discuss in therapy. The therapist should assist the patient in giving up his or her old role. may be some of the only relationships the patient has. Patients with interpersonal sensitivities may have few. but it is important to be flexible when using them. including both positive and negative aspects. patients with interpersonal sensitivities often require a somewhat different approach than is used with patients who have better social skills.Brief Interpersonal Psychotherapy 149 demand for new social or other skills. particularly because the time available in IPT is. It is crucial to help the patient to develop a realistic and balanced view of his or her old role. avoidant attachment styles. Assisting the patient to develop new social supports and skills is also an essential part of the therapy. or other factors. Above all. The therapist should be prepared to give feedback to the patient about the way he or she communicates in therapy and should be prepared to use role-playing as a means of practicing skills with the patient. Rather than “diagnosing” a specific category. Interpersonal sensitivity (Stuart and Robertson 2003) refers specifically to a patient’s difficulty in establishing and maintaining interpersonal relationships. the therapist and patient must keep in mind that the therapy is not designed to “correct” the social difficulties but rather to teach the patient some skills with which he or she can continue to build new relationships and to relieve his or her acute distress. In addition. A diminishment of self-esteem and depression may result.

she responded that her only satisfying relationship was with her baby daughter. Given the biopsychosocial diathesis stress model of illness that is used in IPT (Stuart and Robertson 2003). She was not taking any oral . 1979). In general. She denied any thoughts of self-harm and also denied any thoughts of harm toward her baby. Mrs. R was in training. so that he could begin his residency training in internal medicine at the local hospital. R. Although more empirical data are needed. This was particularly evident in her relationship with Mr. and a poor appetite. R. They had moved within the last year. it is common practice for IPT and medication to be used together to treat psychiatric illnesses. was 3 months postpartum. The therapeutic alliance should not be sacrificed for the sake of a “correct diagnosis” of the problem area. R Mrs. For example. R denied any previous psychiatric problems. the use of medication is theoretically defensible as well. the original studies of IPT reported that combination treatment was more successful and better accepted by patients than either medication or psychotherapy alone (Weissman et al. She had been married 4 years to a “relatively” supportive husband. and in the process had moved some distance from family and friends. Summary Case Illustration: Mrs. Mrs. then the grief area should be used. if the patient feels that his or her recent divorce is a grief issue rather than a role transition. The only complicating factor was that she was breast-feeding and wanted to continue doing so for at least a year and did not want to consider any medication because she did not want to expose her baby to potentially harmful drugs. the patient’s view of the nature of the problem should be accepted. low energy. She also noted no medical problems and reported that her pregnancy and postpartum course to date were unremarkable. effort always should be directed toward improving the patient’s social supports (Stuart and Robertson 2003). When asked about such thoughts.150 The Art and Science of Brief Psychotherapies by definition. limited. The interpersonal problems experienced by patients are similar in that they all derive from an acute interpersonal stressor combined with a social support system that does not sufficiently sustain the patient. R described that her pregnancy was planned but reported that she and her husband had decided to have a baby largely because their medical costs would be covered while Mr. She reported that she felt depressed at times. Interpersonal Psychotherapy and Medication The use of medication is perfectly compatible with IPT—in fact. Her current complaints included trouble sleeping. In addition to addressing the specific problem. but her primary mood was irritability. a 27-year-old woman.

R mutually identified two primary problems. She had been quite successful in school and impressed the therapist with her intellect and insight. The first was a role transition in which she was faced with being a new mother. and Mrs. R described these. she found that it was not the same as getting support in person. R had an older sister with two children.M. They agreed to meet for 12 sessions during the next several months. although she was never treated. Mrs. and her sister had experienced no difficulty with either child. My husband got home around 8:00 P. R: Two nights ago was typical. She did report that her parents highly valued education and were fairly demanding about her academics but not to a degree she considered to be outside of the norm.. She attributed this to the time needed to get established and the subsequent need to stay at home with the baby. much less do anything else!” She denied any formal family psychiatric history but did note that her mother had remarked on several occasions that she might have had postpartum depression. The therapist also felt strongly that in addition to these problems. R had completed a master’s degree in psychology and had started her doctoral work. tell me about one of the more recent conflicts you and Mr. birth control isn’t a problem because I don’t even want my husband to touch me. She was clear that he was not emotionally supportive and that he was not meeting her expectations regarding help with child care. She did have plans to resume her education. the therapist and Mrs. a role that was both unfamiliar and about which she had some ambivalent feelings. R decided that she would put her work on hold both to accommodate the move to another city and to allow her to care for the baby. She had several good friends in the city in which she had lived previously. Her early childhood and development were unremarkable. she began to realize that her communication was not clear and that she at times expected her husband to literally “anticipate” her need for help without her having to ask him for specific help. Over the next several sessions. but it was not clear when that would occur. The second was a conflict with her husband. Both were professors at a university distant from her current residence. but she and Mr. Mrs. R have had about child-care duties. One particular incident highlighted this communication style: Therapist: Mrs. and although she frequently talked on the telephone with them. the therapist elicited several detailed interactions between Mr. She tended to interpret this failure on his part as a lack of emotional support. Mrs. she noted that she had not made any close friends after the most recent move. and I was upset because he had not called to let . As Mrs. Mrs. After the therapist conducted an interpersonal inventory. R. and conflict-avoidant. honest. Mrs. R described herself as hardworking. Furthermore. R. She denied any use of substances other than occasional alcohol and stated that she had only recently had her first glass of wine in more than a year. R would benefit greatly from increased social contact and support.Brief Interpersonal Psychotherapy 151 contraceptives and laughingly stated that “at the moment. having forsworn any alcohol during the pregnancy.

R: It didn’t really—he went to bed early and then left for the hospital early in the morning.” Therapist: And what did Mr. Also. R: I took Jennifer over to the table with me and started eating. . Therapist: It sounds to me that you have a mismatch in needs when he arrives home from work. Therapist: Tell me more about what exactly was said. R had several lengthy discussions with Mr. I don’t think he realizes how much work is involved. communication with him. things aren’t going to get any better. Mrs. he just walked in. R? Mrs. Therapist: So.… Therapist: What ways can you think of that you can address this more directly? Mrs. Over the next several weeks. Mrs. [Somewhat sheepishly] I found out the next day that he had been in surgery most of the evening and couldn’t get out of the operating room to call me. and let him know what I need from him. My husband eventually came over. R: I hadn’t thought of it in that way. R: He didn’t say anything. R: Well.…He’s so inconsiderate. and I was even more irritated about that.152 The Art and Science of Brief Psychotherapies me know that he was going to be late. but it seems pretty clear that if I don’t address this with him directly. Mrs. What was it exactly that you were trying to communicate to Mr. R say in response? Mrs. I just wish he would recognize what I need. Therapist: How well do you think he understood that from your communication. I had waited for him for dinner. R: Well. especially the nonverbal communication and silence that you used in the incident you described? Mrs. how did the interaction end? Mrs. and I’m pretty desperate for someone to talk to at the end of the day. he has a lot of interaction with other people. and you really need some interaction. R: I doubt he got any of it. I don’t really want to do it. He probably needs a break from people. I see—you could have called to let me know. that I was feeling frustrated and that I needed some help and some adult interaction after being cooped up all day with Jennifer. R about her need for time with him. and turned on the TV. this weekend he has some time off from his clinical responsibilities. The net result seems to be that you both get angry and withdraw. and neither of you gets what you want and need. Therapist: And then? Mrs. Therapist: It sounds to me that there was a lot of nonverbal communication in that interaction. and we pretty much sat there in silence the whole meal. “Late again. sat down on the couch. so maybe we could spend some time talking. R: I said.

Mrs. In addition. R had discovered that Mr. To accomplish this. R that she begin making some additional efforts to enlarge her social network. She found these to be extremely helpful both because the women were able to understand and empathize with her situation and because they fulfilled much of her need for adult social contact. she reluctantly attended a group and found instead that there were many women in very similar situations. and although she continued to feel that she bore the weight of the responsibilities because of his work schedule.” After session 4. . Over the course of therapy. She even arranged to meet with two of the other women for coffee the next week. was of great help. therapy also focused on the role transition in which she was engaged. At session 10. R continued to do well and at the end of therapy agreed to contact the therapist should problems arise in the future. R had improved greatly and that she was “enjoying life again. coupled with Mr. Over the course of therapy. as well as talking about them with other women in similar circumstances. she was clear that he was making an effort and wanted to help. R and the therapist reviewed her progress and discussed her understanding of what had led to her difficulties. She reported that giving voice to these ambivalent feelings. the friendships that she was developing had also met many of her social needs and provided empathic support. She also discussed with her husband her desire to return to school part-time within the next 2 years. The greater time and spontaneity that they had enjoyed previously simply was not available anymore but could be compensated for by scheduling time. he specifically suggested that she try out a support group for the spouses of residents employed at the hospital. R described that the stress of having a baby. In addition to these two issues. In addition. She was initially resistant because she was concerned that the women there “would only be interested in being moms and wouldn’t understand my interest in education and other intellectual things. She also emphasized that her relationship with Mr.Brief Interpersonal Psychotherapy 153 and physical help with child care. She clearly felt very attached to Jennifer and loved her dearly but also was aware that she had put plans for further schooling on hold and that she had given up a great deal of spontaneity as well. Mrs. they had arranged for a babysitter on two occasions and had gone out together without the baby. she established friendships with several other women with small children. he was quite receptive to her requests. and to maintain their relationship. Before therapy concluded. the therapist suggested to Mrs. R was quite insightful and readily described mixed feelings about her daughter.” The last two sessions were spaced over a 2-month period. which took them away from familiar social supports. R’s diminished availability because of his residency schedule and the move they had made. Mrs. she was coping with them much better. R was stressed out as well. Mrs. had made it much more difficult to cope with things. the two of them needed to schedule time together. To her surprise. Mrs. She felt that even though there continued to be stressors. many of whom had small children and had moved from other places.

or a difficult life transition. to realistically assess their expectations of others. and a focus on relationships outside of therapy rather than on the transference relationship. This should help resolve interpersonal problems and reduce suffering. and potential problems that may arise in therapy. IPT is an efficacious. however.154 The Art and Science of Brief Psychotherapies Summary IPT is characterized by three essential elements: a focus on interpersonal relationships. Third. and to improve their social support in general. the goal of IPT is to assist the patient in getting his or her attachment needs met more effectively given his or her attachment style. the practice of IPT should rest on the empirical research that supports its use. the practice of IPT should include the use of clinical judgment: the therapist must recognize the unique nature of his or her relationship with each patient and must always place the needs of the patient above strict adherence to a manual. First. Research is under way to investigate more applications of the treatment. Finally. Given these foundational supports. an interpersonal dispute. and 2) their social support network is not sufficient to sustain them through the interpersonal crisis. that IPT also works well for patients with various DSM-IV-TR diagnoses and that even patients with personality problems may benefit from treatment. a contract that specifies a time limit for therapy. the patient’s attachment style should inform the therapist about the ways in which the therapy can be modified to be more effective for patients with less secure attachment styles. Second. and extremely useful clinical approach to interpersonal problems. In essence. IPT must be based on a three-point foundation. and the attachment style of the patient should instruct the therapist about the patient’s suitability for treatment. An acute interpersonal crisis. . Furthermore. effective. IPT helps patients to communicate more effectively to meet their attachment needs. and most important. the practice of IPT should reflect clinical experience with its use. such as a loss. Attachment theory supports the approach used in IPT. Both clinical experience and research evidence make clear. Interpersonal problems and psychiatric symptoms are conceptualized as developing within a biopsychosocial context. creates problems for people for two reasons: 1) their interpersonal communication skills within their significant relationships are not adaptive. IPT is best suited to patients who are more securely attached and who present with more specific interpersonal problems. prognosis.

Watkins JT. Arch Gen Psychiatry 57:1039–1045. Dimascio A. New York. Stuart S. Edward Arnold. Clinical Psychology: Science and Practice 2:349–369. 2000 Rogers CR: The necessary and sufficient conditions of therapeutic personality change. New York. 1957 Stuart S. Frank E. Watkins LM: Interpersonal complementarity and the therapeutic alliance: a study of the relationship in psychotherapy. 1984 Kupfer DJ. Shea MT. Basic Books. 1988 Elkin I. 1995 Frank E. Gorman L. Prusoff BA. Rush AJ. Arch Gen Psychiatry 49:769–773. and future directions. et al: National Institute of Mental Health Treatment of Depression Collaborative Research Program: general effectiveness of treatments. 1989 Frank E. Spanier C: Interpersonal psychotherapy for depression: overview. Text Revision. New York. Rounsaville BJ. Guilford. et al: The efficacy of drugs and psychotherapy in the treatment of acute depressive episodes. Perel JM: Three-year outcomes for maintenance therapies in recurrent depression. clinical efficacy. et al: Efficacy of interpersonal psychotherapy for postpartum depression.Brief Interpersonal Psychotherapy 155 References American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. Klerman GL: Comprehensive Guide to Interpersonal Psychotherapy. 1990 Frank J: Therapeutic factors in psychotherapy. Noyes R: Attachment and interpersonal communication in somatization disorder. Basic Books. 1971 Kiesler DJ. Am J Psychiatry 145:1–10. 1989 Klerman GL. J Consult Psychol 21:95–103. Shaw BF. Washington. 1992 O’Hara MW. DC. London. 2000 . 4th Edition. Kupfer DJ. Am J Psychother 25:350–361. Arch Gen Psychiatry 46:971–982. Arch Gen Psychiatry 47:1093–1099. Perel JM: Five year outcomes for maintenance therapies in recurrent depression. 1979 Bowlby J: Developmental psychiatry comes of age. 1999 Stuart S. Psychotherapy 26:183– 194. Am J Psychiatry 136: 555–558. Weissman MM. 1979 Weissman MM. et al: Interpersonal Psychotherapy of Depression. Psychosomatics 40:34–43. 2000 Beck AT. 2003 Weissman MM. Markowitz JW. et al: Cognitive Therapy of Depression. American Psychiatric Association. Robertson M: Interpersonal Psychotherapy: A Clinician’s Guide.

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” Journal of Psychotherapy Integration 13:300–333. “We don’t say ‘cure.D.’ ” Therapist [Billy Crystal] to gangster/patient [Robert DeNiro] in the movie Analyze This Some material in this chapter is from Time-Limited Psychotherapy: A Guide to Clinical Practice (copyright © 1995 by Hanna Levenson. 2003.’ We say you had a ‘corrective emotional experience. reprinted by permission of Basic Books.6 Time-Limited Dynamic Psychotherapy Formulation and Intervention Hanna Levenson. 157 . LLC) and from “Time-Limited Dynamic Psychotherapy: An Integrationist Approach. Ph. a member of Perseus Books.

images of the self and others evolve out of human interactions rather than out of biologically derived tensions. TLDP makes use of the relationship that develops between therapist and patient to kindle fundamental changes in the way a person interacts with others and himself or herself. the self is seen as an internalization of interactions with significant others. and training relevant to TLDP and illustrate its practice with a case study.158 The Art and Science of Brief Psychotherapies ime-limited dynamic psychotherapy (TLDP) is an interpersonal. Time-Limited Dynamic Psychotherapy: A Guide to Clinical Practice. 2002a). T Overview TLDP was first formalized in a treatment manual constructed for a research program investigating briefer ways of intervening with challenging patients. time pressures help keep the therapist attuned to circumscribed goals with an active. According to object relations theory. Its premises and techniques are broadly applicable regardless of time limits. Historically. This relational view sharply contrasts with that of classical psychoanalysis. timesensitive approach for patients with chronic. I review theory. and accountability (Levenson et al. TLDP is rooted in an object relations framework. by emphasizing the role of the therapeutic relationship in evoking and resolving past problem patterns. the . dysfunctional ways of relating to others. research. In a more recently published clinical casebook. Furthermore. directive stance (Levenson et al. Levenson (1995) translated TLDP principles and strategies into pragmatically useful ways of thinking and intervening for the practitioner. however. Specifically. flexibility. This manual eventually was reproduced in book form: Psychotherapy in a New Key: A Guide to Time-Limited Dynamic Psychotherapy (Strupp and Binder 1984). The focus is not on the reduction of symptoms per se (although such improvements are expected to occur) but rather on changing ingrained patterns of interpersonal relatedness or personality style. which emphasizes the role of innate mental structures in mediating conflicts between instinctual impulses and societal constraints. The Levenson text places more emphasis on behavioral changes through experiential learning than on insight through interpretation. TLDP maintains continuity with psychoanalytic modalities. 2002b). However. The search for and maintenance of human relatedness are considered to be major motivating forces within all human beings. pervasive. Indeed. In this chapter. its method of formulating and intervening makes it particularly well suited for the so-called difficult patient seen in a brief or time-limited therapy. The brevity of the treatment promotes therapist pragmatism.

Data from child development research (e.. as exemplified by the early work of Sullivan (1953). Maladaptive relationship patterns are learned in the past—Disturbances in adult interpersonal relatedness typically stem from faulty relationships with early caregivers—usually in the parental home. Bowlby . Essential Assumptions The TLDP model makes five basic assumptions that greatly affect treatment: 1. Stern 1985) point to how one’s world is essentially interpersonal. allowing for meaningful psychotherapy integration (see Greenberg. p. Strupp and Binder (1984) made clear that their “purpose is neither to construct a new theory of personality development nor to attempt a systematic integration of existing theories. other theories of psychotherapy are also incorporating interpersonal perspectives in their conceptualizations and practice. we have chosen interpersonal conceptions as a framework for the proposed form of psychotherapy because of their hypothesized relevance and utility” (p. Recent information from the field of neurobiology suggests that “relationships early in life may shape the very structures that create representations of experience and allow a coherent view of the world. Rather. TLDP embraces an interpersonal perspective. Interpersonal experiences directly influence how we mentally construct reality” (emphasis added. in this volume). and gestalt therapy. This can be seen in cognitive therapy. Siegel 1999. Similarly. 28). Interestingly. Transference (the repetition of past conflicts within the therapeutic relationship) is not considered a distortion but rather a patient’s plausible perceptions of the therapist’s behavior and intent. behavior therapy. Rather. it represents his or her natural reactions to the pushes and pulls from interacting with patients. Chapter 8. and is consistent with the views of modern interpersonal theorists.g. The relational view of TLDP focuses on transactional patterns in which the therapist is embedded in the therapeutic relationship as a participant observer. 4). This growing recognition of the import of interpersonal relatedness promotes compatibility across a variety of theoretical and strategic viewpoints. countertransference (the emergence of a therapist’s emotional patterns within the therapy) does not indicate a failure on the part of the therapist.Time-Limited Dynamic Psychotherapy 159 TLDP interpersonal perspective reflects a larger paradigm shift occurring within psychoanalytic theory and practice from a one-person to a twoperson psychology (Messer and Warren 1995).

This reenactment is an ideal therapeutic opportunity because it permits the therapist to observe the playing out of the maladaptive interactional pattern and to experience what it is like to try to relate to that individual. For example. including the current patient–therapist relationship. 3. this style must be supported in the person’s current adult life for the interpersonal difficulties to continue. inform one about the nature of human relatedness and what is generally necessary to sustain and maintain emotional connectedness to others. Working in the present allows change to happen more quickly because there is no assumption that one needs to work through child- . as others unwittingly replicate familiar responses from one’s troubled past. These models. which allows them to interpret the present. transference) and tries to enlist the therapist into playing a complementary role. Maladaptive patterns are maintained through their enactment in the current social system. which stresses the context of a situation and the circular processes surrounding it. “Pathology” does not reside within an individual but rather is created by all the components within the (pathological) system. and anticipate the future. or schemas. if a child has learned to be placating and deferential because he or she grew up in a home with authoritarian parents. Dysfunctional relationship patterns are reenacted in vivo in the therapy— A third assumption is that the patient interacts with the therapist in the same dysfunctional way that characterizes his or her interactions with significant others (i. 4). understand the past. the therapist can concentrate on the present to alter the patient’s dysfunctional interactive style. From a TLDP framework. Because dysfunctional interactions are presumably sustained in the present. that child will unwittingly and inadvertently attempt to maintain this role as an adult by encouraging others to act harshly toward him or her. Children filter the world through the lenses of these schemas.e. Such maladaptive patterns are maintained in the present—This emphasis on early childhood experiences is consistent with much of psychoanalytic thinking. 2. this “shaping process occurs throughout life” (Siegel 1999. Data from neurobiology research appear to confirm that although relationships play a crucial role in the early years. p.. This focus is consistent with a systems-oriented approach. however. the individual’s personality is seen not as fixed at a certain point but rather as continually changing as it interacts with others.160 The Art and Science of Brief Psychotherapies (1973) elaborated that early experiences with parental figures result in mental representations of these relationships or working models of one’s interpersonal world. Although one’s dysfunctional interactive style is learned early in life.

the therapist can collaboratively invite the patient to look at what is happening between them (i. patients induce therapists to act as “accomplices. In Sullivan’s (1953) terms. In addition. or in Wachtel’s (1987) terms. The therapist inevitably becomes “hooked” into acting out the corresponding response to the patient’s inflexible. To get “unhooked. This emphasis on the present has tremendous implications for treating interpersonal difficulties in a brief time frame.. children who have experienced serious family dysfunction are thought to have disorganized internal mental structures and processes as a result.” the therapist must realize how he or she is fostering a replication of the dysfunctional pattern. which causes others not to respond to the child in empathic ways. maladaptive twostep has its parallels in the recursive aspect of mental development. This is not to say that . thereby engaging the patient in a healthier mode of relating. 4. thereby disorganizing the development of the mind further. maladaptive pattern.e. This transactional type of reciprocity and complementarity (what I call interactional countertransference) does not indicate a failure on the part of the therapist but rather represents his or her “role responsiveness” or “interpersonal empathy” (Strupp and Binder 1984). the therapist inevitably will be pushed and pulled by the patient’s dysfunctional style and will respond accordingly. For example. the emphasis in TLDP is on discerning a patient’s most pervasive and problematic style of relating (which may need to incorporate several divergent views of self and other). 5. These disorganized processes impair the child’s behavior with others. the therapist becomes a participant observer.” That the therapist is invited repeatedly by the patient (unconsciously) to become a partner in a well-rehearsed. The relationalinteractionist position of TLDP holds that the therapist cannot help but react to the patient—that is. The TLDP focus is on the chief problematic relationship pattern— Although patients may have a repertoire of different interpersonal patterns. The TLDP practitioner uses this information to attempt to change the nature of the interaction in a positive way.Time-Limited Dynamic Psychotherapy 161 hood conflicts and discover historical truths. The therapeutic relationship has a dyadic quality—A corollary assumption to the TLDP concept of transference is that the therapist also enters into the relationship and becomes a part of the reenactment of the dysfunctional interpersonal interaction. either highlighting the dysfunctional reenactment while it is occurring or solidifying new experiential learning following a more functionally adaptive interactive process. metacommunicate).

From a TLDP perspective. going to a movie alone). The new experience is actually composed of a set of focused experiences throughout the therapy in which the patient gains a different appreciation of self.g. The presence of a clear interpersonal focus is an important element distinguishing timelimited psychoanalytic therapy from longer-term efforts at personality reconstruction.g. The focus of these new experiences centers on those that are particularly helpful to a patient based on the therapist’s formulation of the case (see “Time-Limited Dynamic Psychotherapy Formulation” later in this chapter). of the therapist.. healthier) than the maladaptive pattern to which the person has become accustomed. and of their interaction. more flexibly. This in vivo learning is a critical component in the practice of TLDP. These new experiences provide the patient with experiential learning so that old patterns may be relinquished and new patterns may evolve. . And experience emphasizes the affective-action component of change—behaving differently and emotionally appreciating the different behavior. This information then informs the patient’s internal representations of what can be expected from self and others. The therapist identifies what he or she could say or do (within the therapeutic role) that would most likely subvert or interrupt the patient’s maladaptive interactive style.e. see how they feel.. New Experiences The first and major goal in conducting TLDP is offering the patient a new relational experience. behaviors are encouraged that signify a new manner of interacting (e.162 The Art and Science of Brief Psychotherapies other relationship patterns may not be important. New is meant in the sense of being different and more functional (i.. and notice how the therapist responds. content-based behaviors (e. The patient can actively try out (consciously or unconsciously) new behaviors in the therapy. Goals The TLDP therapist seeks two overriding goals with patients: new experiences and new understandings. The therapist’s behavior gives the patient the opportunity to disconfirm his or her interpersonal schemas. more independently) rather than specific. However. focusing on the most frequently troublesome type of interaction should have ramifications for other less central interpersonal schemas and is pragmatically essential when time is of the essence.

new learning takes place. here-and-now process is thought to “heat up” the therapeutic process and permit progress to be made more quickly than in therapies that depend solely on more abstract learning (usually through interpretation and clarification). “What the patient needs is an experience.” There are definite parallels between the goal of a new experience and procedures used in some behavioral techniques (e.Time-Limited Dynamic Psychotherapy 163 These experiential forays into what for the patient has been frightening territory make for heightened affective learning. From an empirical standpoint. not an explanation. It questions the pursuit of insight as a necessary goal and thereby challenges the use of interpretation as the cornerstone of psychodynamic technique. Such an emotionally intense. Out of this tension.g. in which clients are exposed to feared stimuli without the expected negative consequences. Modern cognitive theorists voice analogous perspectives when they talk about interpersonal processes that lead to experiential disconfirmation. Similarities can also be found in the plan formulation method (Sampson and Weiss 1986). In their classic book. Alexander and French challenged the then-prevalent assumption concerning the therapeutic importance of exposing repressed memories and providing a genetic reconstruction. This view has major implications for the techniques one uses. As Frieda Fromm-Reichmann is credited with saying. in which opportunities for change occur when patients test their pathogenic beliefs in the context of the therapeutic relationship. The concept of a corrective emotional experience described more than 50 years ago is also applicable (Alexander and French 1946). exposure therapy). I believe this experiential learning is important for doing brief therapy and becomes critical when working with a patient who has difficulty establishing a therapeutic alliance or exploring relational issues in the here and now. Psychoanalytic Therapy: Principles and Applications. Decades of clinical and empirical data within psychology clearly support this conclusion (Fisher and Greenberg 1997). they suggested that change could take place even without the patient’s insight into the etiology of his or her problems. Alexander and French’s (1946) concept of the corrective emotional experience has been criticized for promoting manipulation of the transference by suggesting that the therapist should respond in a way diamet- . Henry and colleagues (1994) presented data indicating that transference interpretations in particular may not be effective and may even be countertherapeutic. Now.. neurobiological data appear to indicate that most learning is done without conscious awareness (Siegel 1999). A tension is created when the familiar (but detrimental) responses to the patient’s presentation are not provided. By focusing on the importance of experiential learning.

placing the new experience in the foreground helps them regroup and focus on the “big picture”—how not to reenact a dysfunctional scenario with the patient. In addition. which emphasizes the affective-behavioral arena. . The TLDP concept of the new relational experience does not involve a direct manipulation of the transference and is not solely accomplished by the offering of a “good enough” therapeutic relationship. the TLDP therapist can point out repetitive patterns that have originated in experiences with past significant others. because psychodynamically trained therapists are so ready to intervene with an interpretation. It is my current thinking that experiential learning broadens the range of patients who can benefit from brief therapies. Specifically. This emphasis on the new experience is a departure from the central role of understanding through interpretation in the original TLDP model (Strupp and Binder 1984). If undertaken in a constructive and sensitive manner. mature. and in the here and now with the therapist.164 The Art and Science of Brief Psychotherapies rically opposite to that expected by the patient. for example. leads to more generalization to the outside world. such disclosure allows patients to recognize similar relationship patterns with different people in their lives. To facilitate such a new understanding. A warm stance that supports a patient’s independence. then the therapist should maintain a more restrained stance. providing a new understanding. Differentiating between the idea of a new experience and a new understanding helps the clinician attend to aspects of the change process that would be most helpful in formulating and intervening as efficiently and effectively as possible. The patient’s new understanding usually involves an identification and comprehension of his or her dysfunctional patterns. a therapist can help provide a new experience by selectively choosing—from all of the helpful. focuses more specifically on cognitive changes than the first goal just discussed. if the patient was raised by an intrusive mother. Therapists’ judicious disclosing of their own reactions to patients’ behaviors also can be beneficial. This new perspective enables them to examine their active role in perpetuating dysfunctional interactions. New Understandings The second goal. For example. and respectful ways of being present in a session—those particular aspects that would most effectively undermine a specific patient’s dysfunctional style. and permits therapists to incorporate a variety of techniques and strategies that might be helpful. with current significant others. may counter expectations of intrusiveness as readily as a stance of restraint would.

Rather. Again. in the give-and-take of the therapeutic encounters. Also. However.Time-Limited Dynamic Psychotherapy 165 Inclusion and Exclusion Criteria TLDP was developed to help therapists deal with patients who have trouble forming working alliances because of their lifelong dysfunctional interpersonal difficulties. Patients should be capable of having a meaningful relationship with the therapist. 57). Previously. as long as adequate descriptions of their interpersonal transactions can be elicited. 3. Strupp and Binder (1984) elaborated that the patient needs to possess “sufficient capacity to emotionally distance from these feelings so that the patient and therapist can jointly examine them” (p. I (Levenson 1995) endorsed the TLDP selection criteria as outlined by Strupp and Binder (1984). negative attitudes. Later. Because of my emphasis on the experiential goal. Patients must be willing to consider how their relationships have contributed to distressing symptoms. 2. emptiness) that affect their relatedness to self and other. effort. depression. it could be applicable for anyone who is having difficulties (e. Patients must come for appointments and engage with the therapist—or at least talk. Patients must be in emotional discomfort so that they are motivated to endure the often challenging and painful change process and to make sacrifices of time. the strength of the patient’s ability to step back from feelings and metacommunicate what is going on is less important than in the original model. Initially.g. The operative word here is willing. Suitable patients do not actually have to walk in the door indicating that they have made this connection. But the potential for establishing such a relationship should exist. The following five major selection criteria are used to determine a patient’s appropriateness for TLDP: 1. such an attitude may be fostered by hope or faith in a positive outcome. 5. anxiety. Patients cannot be out of touch with reality or . Patients must be willing to examine feelings that may hinder more successful relationships and may foster more dysfunctional ones. 4. it is not expected that the patient initially relate in a collaborative manner. they show signs of being willing to entertain the possibility. and money as required by therapy. Note that they do not have to understand the nature of interpersonal difficulties or admit responsibility for them to meet this selection criterion. and/or behavioral difficulties. it might stem from actual experiences of the therapist as a helpful partner.. My current thinking is that TLDP may be helpful to patients even when they do not quite meet these criteria.

serves as a guide for interventions. and clinical savvy to devise formulations of cases. It describes the nature of the problem. the problematic interpersonal scenario may never be stated per se. For some patients with minimal capacity for introspection and abstraction. incorporating major components of a person’s current and historical interactive world. insight. and enables the therapist to anticipate reenactments within the context of the therapeutic interaction. The cyclical maladaptive pattern also provides a . These cycles or patterns involve inflexible. It is not necessarily shared with the patient but may well be. psychodynamic brief therapists used their intuition. but they are impossible to teach explicitly.166 The Art and Science of Brief Psychotherapies be so impaired that they have difficulty appreciating that their therapists are separate people. A successful TLDP formulation should provide a blueprint for the therapy. self-defeating expectations and behaviors and negative self-appraisals that lead to dysfunctional and maladaptive interactions with others. the content may remain very close to the presenting problems and concerns of the patient. Rather. In these cases. In either case. Briefly. Other patients enter therapy with a fairly good understanding of their self-perpetuating interpersonal patterns. and readily recognize the behavior’s occurrence in the therapy. Development and use of the cyclical maladaptive pattern in treatment is essential to TLDP (Levenson and Strupp 1997). the cyclical maladaptive pattern outlines the idiosyncratic vicious cycle (Wachtel 1997) of maladaptive interactions that a particular patient manifests with others. These methods may work wonderfully for the gifted or experienced therapist. One remedy for this situation was the development of a procedure for deriving a dynamic. the therapist and patient can jointly articulate the parameters that foster such behavior. generalize to other situations as applicable. It provides an organizational framework that makes a large mass of data comprehensible and leads to fruitful hypotheses. interpersonal focus— the cyclical maladaptive pattern (Binder and Strupp 1991). A cyclical maladaptive pattern should not be seen as an encapsulated version of truth but rather as a plausible narrative. It is a map of the territory—not the territory itself (Strupp and Binder 1984). leads to the delineation of goals. depending on the patient’s abilities to deal with the material. the cyclical maladaptive pattern plays a key role in guiding the clinician in formulating a treatment plan. Formulation Cyclical Maladaptive Pattern In the past.

Acts of others toward the self—This third grouping consists of the actual behaviors of other people. Thus. “When I meet strangers. motives. Sometimes these acts are conscious. education). my boss shunned me for the rest of the day. no one will ask me to dance. in terms of both outcome at termination and in-session mini-outcomes. The therapist then explores the interpersonal context of the patient’s symptoms or problems (step 2). perceptions. and behaviors of the patient of an interpersonal nature.” “When I went to the dance. For example. and probe for clinical information: 1. guys asked me to dance but only because they felt sorry for me. organize. as those above are. When did the problems begin? What else was going on in the patient’s life at that time.” “If I go to the dance. dramatically) as well as to the content. feelings.g. there are possibilities for the therapy to be briefer and more effective. “When I made a mistake at work. as observed (or assumed) and interpreted by the patient. and sometimes they are outside awareness. Acts of the self—These acts include the thoughts. 2.Time-Limited Dynamic Psychotherapy 167 way to assess whether the therapy is on the right track. Constructing the Cyclical Maladaptive Pattern To derive a TLDP formulation.” 3. developmental history. the therapist can learn much about the patient’s interpersonal style. This process is facilitated by using four categories to gather.. Acts of the self toward the self (introjection)—In this category belong all of the patient’s behaviors or attitudes toward the self—when the self . “I wish I were the life of the party” (motive). the therapist lets the patient tell his or her own story (step 1) in the initial sessions rather than relying on the traditional psychiatric interview that structures the patient’s responses into categories of information (e. Expectations of others’ reactions—This category pertains to all the statements having to do with how the patient imagines others will react to him or her in response to some interpersonal behavior (act of the self). I think they wouldn’t want to have anything to do with me” (thought). The focus provided by the cyclical maladaptive pattern permits the therapist to intervene in ways that have the greatest likelihood of being therapeutic.” 4. as in the case of the woman who does not realize how jealous she is of her sister’s accomplishments. “My boss will fire me if I make a mistake. cautiously. deferentially. “I am afraid to take the promotion” (feeling). especially of an interpersonal nature? The clinician obtains data that will be used to construct a cyclical maladaptive pattern (step 3).g.. By listening to how the patient tells his or her story (e.

One’s reactions to the patient should make sense given the patient’s interpersonal pattern. the therapist is able to plan appropriately. ruptures in the therapeutic alliance.” “When no one asked me to dance. By anticipating patient resistances. the new understanding (step 8) of the client’s dysfunctional pattern as it occurs in relationships. By using the four categories of the cyclical maladaptive pattern and the therapist’s own reactions to the developing transactional relationship with the patient. re-creating a dysfunctional dance with the patient. I berated myself so much that I had difficulty sleeping that night. The cyclical maladaptive pattern can be used to foresee likely transference-countertransference reenactments that might inhibit treatment progress. when therapeutic impasses occur. a cyclical maladaptive pattern narrative is developed that describes the patient’s predominant dysfunctional interactive pattern (step 6). and so on.. and unlovable. the influence of the therapist’s personal conflicts is not so paramount as to undermine the therapy).” For the fourth step.168 The Art and Science of Brief Psychotherapies is the object of the interpersonal pattern. The TLDP perspective. time. As part of interacting with the patient. the therapist becomes more aware of his or her countertransferential reenactments (step 5). ugly. After determining the nature of the new experience. By examining the patterns of the here-and-now interaction. This new experience should contain specific transference-countertransference interactions that disconfirm existing negative expectations. From the cyclical maladaptive pattern formulation. The first goal involves determining the nature of the new experience (step 7). the therapist is not caught off guard but rather is prepared to capitalize on the situation and maximize its clinical effect—a necessity when time is of the essence.e. and place. Thus. the therapist then discerns the goals for treatment. each therapist has a unique personality that might contribute to the particular shading of the reaction that is elicited by the patient. and by using the “expectations of others’ reactions” and the “acts of others toward the self” components of the cyclical maladaptive pattern. the therapist then listens for themes in the emerging material by being sensitive to commonalities and redundancies in the patient’s transactional patterns over person. the therapist will be pulled into responding in a complementary fashion. I told myself that it is because I’m fat. How does the patient treat himself or herself? “When I made the mistake. Of course. is that the therapist’s behavior is predominantly shaped by the patient’s evoking patterns (i. the therapist can use the cyclical maladaptive pattern formulation to determine the second goal for treatment. however. .

Rather. it depends on therapeutic strategies that are useful only to the extent that they are embedded in a larger interpersonal relationship. Here. Also. experiential. However. Other Formulation Methods The cyclical maladaptive pattern is only one of the formal ways relationally oriented therapists can represent patterned. They are more willing and (hopefully) able to incorporate a variety of potentially useful strategies as a way of working. therapists are more directive and active. In a brief therapy. modify. the therapist cannot wait to have all the “facts” before formulating the case and intervening. plan diagnosis method (Weiss and Sampson 1986). structural analysis of social behavior (Schacht and Henry 1995). As the therapy proceeds. and patients come to expect this more pragmatic attitude. the 1 For information on more traditional TLDP interventions. in brief therapies. Because the focus is on experiential interpersonal learning. it is critical for the therapist to understand how the meaning and effect of such interventions taken out of their original context might shift when they are incorporated within TLDP. and interpersonal elements. Appendix). . new content and interactional data become available that might strengthen. or negate the working formulation. These steps should not be thought of as separate techniques applied in a linear. I would like to focus on one treatment strategy that incorporates behavioral. Moreover.Time-Limited Dynamic Psychotherapy 169 The last step (9) in the formulation process involves the continuous refinement of the cyclical maladaptive pattern throughout the therapy. This focus on patterned. rigid fashion but rather as guidelines for the therapist to be used in a fluid and interactive manner. theoretically any intervention that facilitates this goal could be used. Therapeutic Strategies Implementation of TLDP does not rely on a set of techniques. interpersonal processes provides meaningful opportunities for therapeutic integration at the formulation and intervention levels. recursive. any intervention (even psychodynamic standbys such as clarification and interpretation) must be assessed with regard to how much it might alter the interpersonal interchange in an undesirable direction or reenact the patient’s cyclical maladaptive pattern. repetitive interpersonal transactions.1 Specifically. the reader is referred to the Vanderbilt Strategies Scale (Levenson 1995. and rolerelationship models configuration (Horowitz 1987). Some others include the core conflictual relationship theme (Luborsky 1984).

T’s lifelong dysfunctional pattern. issues of loss are interwoven through the therapy and do not solely appear in the termination phase. (New experience: The therapist introduces to Ms.) Ms. TLDP is thought to promote change by altering the basic infrastructure of the patient’s transactional world.g. In these cases.. T’s therapist listened with engaged interest to the jokes and did not interrupt. laugh uproariously at Ms. There was no need to do anything feigned (e. T’s joke). the best advice for the TLDP therapist is to maintain the dynamic focus and the goals for treatment. the therapist’s interventions (observing nonverbal behavior. her therapist directed her attention to the contrast between her joking and her anxiously twisting her handkerchief. the therapists’ behavior gave the patients a new interpersonal experience—an opportunity to disconfirm their own interpersonal schemas. S’s maladaptive interpersonal pattern suggested that she had the deeply ingrained belief that she could not be appreciated unless she maintained the role of the charming. With sufficient quality and quantity of these experiences. The following examples illustrate how to intervene with two patients with seemingly similar behaviors but differing experiential goals. Ms. In this way. effervescent ingenue. with roots in attachment theory and object relations theory.) In both cases. listening) were well within the psychodynamic therapist’s acceptable repertoire. Ms. nor was there a demand to respond with a similar therapeutic stance to both presentations. patients can develop different internalized working models of relationships. revise.170 The Art and Science of Brief Psychotherapies therapist needs to provide opportunities for the patient to have new experiences of himself or herself and/or the therapist that are designed to help disrupt. Termination Because TLDP is based on an interpersonal model. She also attempted to joke in the fifth session. . When she attempted to joke throughout most of the fifth session. S the possibility that he can be interested in her even if she is anxious and not entertaining. and improve the patient’s cyclical maladaptive pattern. nervously twisting her handkerchief. (New experience: The therapist can appreciate her taking center stage and not humiliate her when she is so vulnerable. Toward the end of therapy. which then reverberates to influence the concept of self. was a meek stance fostered by repeated ridicule from her alcoholic father. while examining how these patterns appear when loss and separation issues are most salient. in contrast.

clinical service is combined with a comprehensive. Brief Psychotherapy Program training consists of a 1-hour didactic seminar and a 2-hour group supervision per week for five to seven trainees at a time over a 6-month training rotation. Such additional therapy would not be viewed as evidence of a TLDP treatment failure. In fact. it is hoped that patients will view their TLDP as helpful and as a resource to which they could return over time. The didactic portion of the training covers the theoretical and clinical aspects of TLDP. Has there been a change in the level on which the therapist and patient are relating (from parent–child to adult–adult)? 4. Has the patient had interactional changes with significant others in his or her life? Does the patient report more rewarding transactions? 2. At some point in the future. the patient may feel the need to obtain more therapy for similar or different issues. nonprofessional alternatives. Has the patient had a new experience (or a series of new experiences) of himself or herself and the therapist within the therapy? 3. As with most brief therapies. Training In the Brief Psychotherapy Program at the California Pacific Medical Center in San Francisco. Has the therapist’s countertransferential reaction to the patient shifted (usually from negative to positive)? 5. This view of the availability of multiple short-term therapies over the individual’s life span is consistent with the position of the therapist as family practitioner. another course of TLDP. structured training program for psychiatry residents and psychology interns. TLDP is not considered to be the final or definitive intervention. Does the patient manifest some understanding about his or her dynamics and the role he or she was playing to maintain them? If the answer is “no” to more than one of these questions. then the therapist should seriously consider whether the patient has had an adequate course of therapy. The therapist should reflect why this has been the case and weigh the possible benefits of alternative therapies. a different therapist. and so forth. 1. I use five sets of questions to help the therapist judge when termination is appropriate. Videotapes of actual therapy sessions (conducted by the supervisor as well as .Time-Limited Dynamic Psychotherapy 171 How does the TLDP therapist know when the patient has had “enough” therapy? In doing TLDP.

and common therapeutic dilemmas. In this way. They propose interventions. I strongly believe that videotape is an essential part of TLDP training because it provides a vivid account of what actually occurs in therapy. Each trainee is assigned to videotape one patient for an entire therapy (up to 20 sessions) with the TLDP model. 2323 Sacramento Street. trainees learn how the model must be adapted to address the particular dynamics of each case. disclose how they are reacting to the material. CA 94115 (510-6660076). Psychological and Educational Films. Corona del Mar.172 The Art and Science of Brief Psychotherapies by beginning students) are used to illustrate important basic principles. San Francisco. CA 92625 (888-750-4029). which counteracts the negative effects of inert knowledge. 3334 E Coast Highway #252. and supervision focuses on how to devise strategies designed to further the goals consistent with the formulation. In this way. and cancellations). they are asked to describe what is going on in the vignettes and to distinguish between relevant and irrelevant material. 750 First Street NE.2 As trainees watch videotapes of sessions in a stop-frame approach. permitting an examination of the nuances of the therapeutic relationship. illnesses. This format allows trainees to receive peer and supervisory comments on their technique as well as to observe the process of a brief therapy with other patient–therapist dyads. Most important is the focus on specific therapist–patient interactions. They also learn what is generalizable about TLDP across patients. . contact Levenson Institute for Training. DC 20002 (800-374-2721). holidays. by using very brief segments of tape to illustrate interactional sequences. the driving force of the therapy is made explicitly salient. Commercially available instructional videotapes are also used. The average number of actual sessions is approximately 14 (because of vacations. strategies. the realistic context provided by videotape can be used to facilitate an active wrestling with relevant material. Trainees write up their cyclical maladaptive patterns and goals at the beginning of therapy and share these with the others in the class. In addition. Washington. Each trainee privately reviews his or her entire videotape of that week’s session and selects portions to show in the group supervision. and anticipate the moment-to-moment behavior of the patients and therapists. In both instruction and supervision.) 2 For instructional TLDP videotapes. American Psychological Association. think aloud about the reasons for their choices. Second Floor. (See Levenson and Strupp 1999 for specific recommendations concerning training in brief dynamic psychotherapy.

71% of the patients felt that their problems had lessened. Other analyses indicated that patients were more likely to value their therapies the more they perceived that sessions focused on TLDP-congruent strategies (i. .. the nature of therapists’ and patients’ behavior in relation to one another has been shown to be associated with the quality of therapeutic outcome. a series of studies at Vanderbilt University in the 1970s (Vanderbilt I) suggested that therapists become entrapped into reacting with negativity. trying to understand their typical patterns of relating to people. 1994). and disrespect and.e. From the standpoint of psychotherapy process. yielding a steadily growing body of empirical findings pertaining to the process and outcome dimensions of this short-term treatment approach. A recent study examining relational change (Travis et al.Time-Limited Dynamic Psychotherapy 173 Research Several research programs investigating TLDP have been undertaken since the 1970s. antitherapeutically when patients are negative and hostile. exploring childhood relationships. Findings indicated that patient gains from treatment (measured by symptom and interpersonal inventories) were maintained and slightly bolstered. and trying to relate in a new and better way with their therapists). Harrist and colleagues (1994) found that patients internalized both their own and their therapists’ contributions to the therapeutic interaction and that these internalizations were associated with better outcomes. Quintana and Meara (1990) reported that patients’ intrapsychic activity became similar to the way in which they perceived their therapists treated them in short-term therapy. at the time of follow-up. The VA Short-Term Psychotherapy Research Project—the VAST Project—examined TLDP process and outcome in a population with personality disorders (Levenson and Bein 1993). Moreover. hostility. In addition. 2001) found that patients significantly shifted their attachment styles (from insecure to secure) and significantly increased the number of their secure attachment themes following TLDP. 80% of the patients thought that their therapies had helped them deal more effectively with their problems. At termination. patients were reassessed a mean of 3 years after TLDP. in general. In the VAST Project long-term follow-up study (Bein et al. Similarly. It found that approximately 60% of the 89 male patients achieved positive interpersonal or symptomatic outcomes following TLDP (average of 14 sessions). Onefifth of the patients moved into the normal range of scores on a measure of interpersonal problems.

Thus. which consisted of individual sessions with a psychiatrist. and his teenage sons ran away to work on a fishing boat.174 The Art and Science of Brief Psychotherapies With the VAST Project data. guide the issues that are discussed in the therapy. and at one point. U lived his early adult years as a loner. U’s background emerged in a piecemeal fashion as the therapeutic alliance strengthened and Mr. I had been told that he had been given a diagnosis of major depression and was a retired widower with four grown children. U’s father had had alcoholism and that his mother had been “a saint. until they were evicted from their house. Mr. Mr. His goal was to “not be depressed. Perhaps most meaningful is the finding that better outcomes were achieved when these therapies maintained a focus relevant to the patients’ cyclical maladaptive patterns. Mr.” . U said that he felt love for his father until he saw him beat his mother when he was about 10 years old. these preliminary findings indicate that the TLDP case formulations convey reliable interpersonal information to clinicians who are otherwise unfamiliar with the case. Mr. About a year later. U suddenly died of cancer. U became more aware of the relevance of his personal history. Specifically. a 74-year-old man. and milieu therapy. when they came close to divorcing.” Mr. Mr. U then moved into an apartment with his younger son and his son’s girlfriend. When Mrs. I eventually learned that Mr. the youngest of whom was his 10-year-old daughter. His older daughter left to get married. their data indicated that a statistically significant relationship was found between the interpersonal problems raters felt should have been discussed in the therapy (based solely on the patients’ cyclical maladaptive patterns) and those topics the therapists said actually were discussed. was about to be discharged from an inpatient psychiatry unit. U had cooperated with treatment during his 1-month inpatient treatment. U was left to raise four children. U Mr. Mr. he married a woman who was referred to in the inpatient records as “a domineering alcoholic. U. and became a teacher. Hartmann and Levenson (1995) discovered important associations between patients’ cyclical maladaptive patterns and facets of clinical process and outcome. U was hospitalized in a psychiatric unit. Summary Case Illustration: Mr.” The couple had continual marital stress. Much of Mr. and lead to better outcomes when therapists can adhere to them. U was again hospitalized and was subsequently referred to me for outpatient treatment. antidepressant medications. obtained a college degree in education. Sue Ellen left to find a place of her own. U lived with Sue Ellen in an interdependent relationship for 12 years. I knew very little about him prior to our first session. Mr. Sue Ellen. Following this.

U’s cyclical maladaptive pattern. However. U. As he told his story. U’s usual pattern. I considered what new experience of our interaction would provide a healthy disruption in Mr. From this initial cyclical maladaptive pattern.3 Suffice it to say that I was looking for repetitive themes built around the four categories of the cyclical maladaptive pattern. and emotionally disconnected. I strung together the components of the cyclical maladaptive pattern combined with my own reactions to tell a story of his pattern of role relationships. including more elaboration on Mr. He was an isolated. dependent man who expected that others knew best what he should do. I hoped that he could 3 For more specifics on developing a cyclical maladaptive pattern. I reasoned that a more empowered. In addition. so he waited for them to assume responsibility for his life. I was mindful of my own countertransference. I also was aware of having negative feelings toward Mr. . Those themes that occurred over time. and with several different persons gained preeminence. he ended up feeling not helped but rather rejected. Although Mr. Others did step in and direct him because they initially felt sorry for him. This led to his increased isolation and depression. completing the cycle. I assessed that Mr. In addition. irritated. eventually they became frustrated and irritated by his defeatist attitude and sometimes became angry and/or rejected him. U’s recognition that his feelings were important (especially the more energizing ones) would be helpful to him in directing his own life. In terms of a new understanding. U may have initially complied with others’ directives and demands. I also had some feelings of pity for his plight as an elderly man who felt abandoned by his children. U’s rudimentary cyclical maladaptive pattern. I found myself becoming somewhat bored. I cannot fully articulate here how I derived the data for Mr. they were worn down by his complaining. across situations.Time-Limited Dynamic Psychotherapy 175 Formulation Because of space constraints. And the experience of not being rescued from his helplessness nor punished for decisiveness and independence might further encourage him to begin to internalize a new relationship model. and worthless. depressed. Mr. To obtain a narrative of Mr. U presented as the proverbial cork floating on the sea of life. U’s interactive themes. In the first session. see Levenson 1995. he became more helpless and hopeless. or they felt guilty for not wanting to do more. Unable to feel effective and nurtured. unloved. active sense of himself leading to more confident behaviors with me might help jog him out of the familiar rut of his dependency and despondency. Consistent with the behavior from others.

U met the five basic selection criteria. and limited ability to reflect on his own behavior would call for a correspondingly more didactic and directive version of TLDP. that I could become hooked into reenacting several scenarios with him. I wondered if I had already fallen into a countertransferential reenactment of taking too much control and direction. Despite his lack of psychological-mindedness and a depression severe enough to warrant hospitalization. I wanted him to have some awareness that if he changed his customary passive pattern. We’re stranded out there. Whatever you say. Sue Ellen’s leaving and the role you might have played in it? Mr. consisting of the case formulation. When I proposed the focus and time frame. Finally. I concluded that Mr. Given his dependency needs and difficulties with losses. I thought it likely. but we’ve had to move. Therapist: Do you think Sue Ellen’s sorry she moved? . Mr. and anticipated stuck spots in the treatment. And then our being used by real estate people over and over again. U a 20-session brief therapy and suggested that we could focus on ways to help him feel less hopeless and depressed. he would not necessarily be deserted—in fact. But all of a sudden we’re up against it like all the street people almost. he was his own worst enemy.176 The Art and Science of Brief Psychotherapies see that he was already making decisions and taking actions that affected people. I had a rudimentary blueprint of the therapy. U: Yeah. U to appreciate his strengths and capabilities and have some compassion for how and why he might have needed to develop such a style of relating. Course of Treatment Therapist: So this is what has been gnawing away at you. impoverished descriptions of his relationships. By the end of the first session.”). U was characteristically compliant and resigned (“Whatever you say. given Mr. At the conclusion of the first session. and as hopeless as he was. U’s cyclical maladaptive pattern. in many ways. goals. We did have enough money and a pretty happy life. doctor. We’ve had to move. I offered Mr. such as becoming impatient or angry with his passivity. And it’s…I don’t know. U explained that he felt responsible for his daughter’s moving out of the apartment they had shared for 21 years. thereby colluding with his helpless stance. Not over and over again. directive in response to his submission. it would be critical for Mr. but his concrete thinking style. Now Sue Ellen pays too high rent for her salary because she doesn’t have anything left. In the second session. a specific time limit would be expected to raise the saliency of these issues and thereby facilitate the work. Mr. I was encouraged by the relative clarity of his interactive pattern.

And I think I had all these frustrated feelings toward my wife because she was—she insisted on being boss. She says. the… Therapist: [interrupting] How do you feel about what I just said? Mr. Therapist: [matter-of-factly] Well. I’m not that possessive to want her to stick around. “Oh. “I have other things I have to do. I turned on to this young girl all the feelings. U: Anyway. So. I never would have sold the house if they had all stuck together. It’s a fatherly love. [lamenting] Yeah. My statement (“The least she . I feel that she’s unjust or she’s unfair. I don’t see her. I guess these are the things. but they started giving me all kinds of trouble. and my older daughter left me. I don’t really have anybody. So when she died. She’s my little kid. Mr. I was angry inside all the time with her. you know that in your head. I’m feeling sorry for myself. I don’t know…[resigned tone.” it would be a selfish answer on my part. but that’s the truth of the matter. but it’s a real close attachment. Christ. U was angry with his daughter for not being with him in his time of need. At the beginning of the hour. but I’m really asking how your gut feels. U: [begins crying] I don’t want her to go! I want to be with her. [pause] Well. U: What did you say? [pause] At least she could have stuck around? [pause] I’m not that possessive. That’s what I really want. [sighs] Anger at myself for making. for getting rid of a house that could have kept us all together. I turned all my love that I would normally have toward a wife toward this little kid who didn’t leave me. I wondered whether Mr. If I answer that. you are. [pause] Oh. Mr. My two sons left me. I’m really left out. So what it amounts to is that I love Sue Ellen. U: I am. And I don’t want it broken. You know. it would seem like a selfish answer. voice becomes plaintive and trails off] Therapist: The least she could do after you went to all the trouble of raising her and giving her things was to stick around for the rest of your life. Therapist: Well. “Well. And I just feel left out. [pause] you know. [plaintively] She still calls me Daddy. especially given that he was there for her as a child. [pause] If Sue Ellen goes.Time-Limited Dynamic Psychotherapy 177 Mr. If I just said. Because I know kids have to grow up and go their own way. Dad. Really. U: I don’t know.” [mimicking daughter] She says. you know she’s with her friends. And we just withdrew from each other. And she was able to domineer me completely. I have other things to do.” I ask her to come over—I say. Mr. How do you feel about the fact that I said the least she could do is not move out? Mr. and it hurts. [emphatically] It hurts. I just want her in the same household. U: I don’t know.” One of her friends has a boat in College View. But then when she’s gone. “Let’s meet and have an afternoon. Therapist: [nodding] Yeah. I guess she’s forgetting me. my wife and I fought quite a bit. And it really bothered me. They go out on the bay—[pejoratively] baying it. and she always won. I want her to be around.

U did not tell me directly how he was feeling. U to examine what had transpired between us was an opportunity for him to have a new interpersonal experience—specifically. At this point. despite my conscious intentions to be empathic. the goal is not to avoid becoming ensnared in an interactive web with the patient but rather to make use of this entanglement to further the therapeutic process. U probably was having some internal reaction to my provocative statement about his daughter’s obligation to him. U’s cyclical maladaptive pattern. in particular. In addition. In a brief therapy. I was concerned that my harsh comment might have ruptured the developing working relationship between us. 340). to be more assertive in expressing his negative feelings.”) was intended to be an empathic connection with what I sensed was his longing for his daughter and anger toward her that she was not living up to her part of the implicit quid pro quo. I was aware of this reenactment as soon as the words left my mouth (the “observing participant”). possibly causing him to feel criticized and to withdraw—was a mini-reenactment of what transpires outside of therapy. I judged that my provocative statement was a countertransferential reenactment showing my irritation and frustration with his self-pity. Based on my working understanding of Mr. I surmised that Mr. my voice had a sarcastic tone. in his characteristic style. However. [and thereby] increase the likelihood that the patient will begin to be exposed to the therapeutically relevant cues” (Wachtel and McKinney 1992.178 The Art and Science of Brief Psychotherapies could do…was to stick around for the rest of your life. However. U’s changing the subject (“Anyway…”) was another clue that something significant had just transpired. Mr. Mr. U stated that he only “wanted her in the same household. From a TLDP perspective. One of the ways to try to repair a rupture in the therapeutic alliance is to address the patient’s problematic feelings about what is transpiring between therapist and patient. writing on interpersonal processes in cognitive .” My intervention was designed to state “out loud the thought that can’t be spoken. I see such a rupture in the therapeutic alliance as consistent with what Safran and Segal (1990). it is critical to discuss in the here and now of the therapy anything that might contribute to a negative transference. I was hypothesizing that this entire interchange—his passive and martyrlike presentation precipitating my frustration and insensitivity. Could Mr. My hunch was confirmed a few seconds later when Mr. In addition. U avail himself of the opportunity to express his anger (either toward me or about his daughter) and then determine whether there were dire consequences? My stepping back and inviting Mr. Fortunately. p. Thus. I asked him how he felt about what I had just said to him. and the phrasing of my words seemed condescending.

called a “useful window into the patient’s subjective world” (p. U alluded to how he was dominated by his wife. I saw the same theme of his feeling sad and blaming himself rather than feeling anger and confronting others. indirectly) communicated to me his views about our current interaction. such an interpersonal pattern is quite understandable. he switched to complaining that he could not concentrate because he had not had anything to eat that morning. Mr. Repeatedly. Mr. U came to the third session hungry (he had not eaten breakfast) and having soiled his pants (caused by a stool softener). Later in the session. From a TLDP perspective. because he feared that the more direct route would result in physical or emotional abandonment. 89). Would he keep his anger “inside all the time” and “withdraw” from our therapeutic work if I continued to respond to his passivity in a “domineering” fashion? Mr. And we just withdrew from each other. U may have unconsciously (and more safely. U said that he felt sad about having been left alone for 3 days by his family. I hypothesized that he might also have felt angry at being abandoned yet again. Whenever I attempted to engage Mr. Mr. Rather than tell me directly that I was too overbearing. And she was able to domineer me completely. Change me. U’s indirect and childlike stance was preferable to taking the risk of stating his needs and showing his anger.” In this way. Following this interchange. The TLDP therapist should be alert to the possibility that comments about other people are disguised communications about how the patient experiences the therapeutic relationship and what the consequences might be. U: [half-hearted laugh] [pause] There isn’t a place in here where I could get a tomato juice or anything? Therapist: No.” Perhaps I had fallen into an interactional pattern like the one he had had with his wife. alcoholic father. U described what happened when he and his wife had argued—“She always won. However. “Feed me. not here. Interactional psychoanalytic theorists refer to this behavior as an “allusion to the transference. Mr. U in a discussion of his feelings about being left alone. He was almost saying in an infantile fashion. With this information.Time-Limited Dynamic Psychotherapy 179 therapy. it affords the therapist an opportunity to understand more fully the schemas behind a patient’s cyclical maladaptive pattern because the nature of the patient’s underlying characteristic construal of self and others is thereby implied. Given his early childhood experiences with a violent. Mr. . Take care of me. the therapist can learn how to provide the patient with a mini–new experience in the service of modifying the maladaptive schemas sustaining his or her cyclical maladaptive pattern.” I was increasingly more confident in my formulation—Mr.

Therapist: Mr. do you feel that talking with me is difficult because we’ll be talking about some upsetting things. if they have been trained in long-term psychodynamic psychotherapy. Therapist: But right here.. and I haven’t been going out. then you say that it’s more than that. and I’ve been alone for 3 days in the house. U: Well. you are saying two different things.180 The Art and Science of Brief Psychotherapies Mr. or do you think that sitting here talking with me is difficult because you didn’t have breakfast this morning? Mr. I took his response seriously (which does not mean that I automatically believed him) and simply asked him what would keep him from getting something in his stomach right then. U feel more empowered and show more assertive behaviors instead of feeling so dependent and being so compliant. U take a step toward feeling more activated and empowered (i. U the opportunity to make a decision on his own behalf—to take care of what he saw as his needs. Most of the time. I did not interpret his response as an indication of resistance. I was trying to afford Mr. U: [distressed] Oh. I ask the trainees what they would say or do at this point. “It seems like you want to avoid talking about upsetting things”. When he replied that it was because he was hungry. You would have trouble sitting here talking because you’re upset about the things that have gone on this week. In my training classes. I let that goal guide my intervention. U. boy. I like to show the videotape of this session and stop the tape here. The patient is attempting to retain personal integrity and ingrained . “I was wondering if you might be feeling angry because your family abandoned you”. Mr. they volunteer various interpretations (e. the experiential goal emanating from the formulation of the case). Rather. and it would make this session hard anyway. the trainees have no difficulty seeing that their (accurate) interpretations would only serve to make the patient feel worse because they so easily can be heard as blaming indictments. therefore. and they just left. a conclusion reached by interpersonal researchers. Because my goal for the therapy was to have Mr. asked him to clarify whether being hungry or knowing that we would be talking about some upsetting things was making it difficult to be in the session. Resistance from the perspective of TLDP is viewed within the interpersonal sphere as one of many transactions between therapist and patient. I. they decided to go up to Oregon to visit some people. sitting here now. Usually.g. U: I think it’s because I didn’t have breakfast. I ask the students to evaluate whether such communications would help Mr.e. “Does this remind you of how you interact with your family?”). You’re saying that you would have trouble sitting here continuing with our session because you haven’t had breakfast.. After I hear these various interventions.

After this segment. Right here. Nonetheless. Mr. And the dilemma is—can you concentrate and really make use of the time. rather than be rude. you’ll sit there and be uncomfortable for an hour. This would have clearly been the riskier choice and a significant break with his familiar pattern. I feel obligated to come and see you because you’re helping me. U: [sigh] Well. I would feel better. U’s truly having had a new experience if he had chosen to leave the session and chance my displeasure. The patient’s perceptions support his or her understanding of what is required to maintain interpersonal connectedness and safety. In the process of exploring why Mr. Mr. . U. he voiced his decision. the fact that we’re having a session. U did not decide to get something to eat. with me in this room. right now. I interrupted him and said that I was not clear as to what his decision was—whether he had decided to stay or to get something to eat. U: [sigh] Therapist: And what would keep you from deciding to do that? Mr. Therapist: Unless I’d let you go? Mr. After listening to him for a couple of minutes. Therapist: That’s right. Mr. Therapist: Uh-huh. U: Well. I guess so. Therapist: [pause] Mr. U said that he was feeling better and could stay. U: [taken aback] Well. U: If I just got something in my stomach. Mr. Therapist: So.Time-Limited Dynamic Psychotherapy 181 perceptions of himself or herself and others. Mr. I don’t know. I pointed out one level of the interpersonal dynamic that was occurring between us in the here and now: “Your dilemma is whether to take care of you or to take care of me. or do you need some food in you to be able to do that? Your dilemma is whether to take care of you or to take care of me. Unless you’d let me go. U: I’d have to go over to the cafeteria over there. it seems you’re faced with a dilemma. and our interaction around the breakfast issue had raised the salience of his customary way of denying his own needs in favor of what he thinks others want. U tried to avoid making an active decision in the room by simply continuing to talk. I would have felt more secure in Mr.” Exploring patterns that constitute dysfunctional transactions between patient and therapist is a critical step in accomplishing the second goal of helping the patient have a new understanding. And what keeps you from getting something in your stomach right now? Mr. Resistance in this light is the patient’s attempt to do the best he or she can with how he or she construes the world. and I don’t want to be rude.

U’s affect directly several times without success. I then asked him what he was feeling at those moments. or incited to delve deeper by his withholding. I hoped to avert his hypersensitivity to being blamed. My next intervention was psychoeducational. My goal here was to help him become curious about his own behaviors as markers for understanding his feelings and the effect he had on others. you tear up and your voice gets a little quivery. he was not willing to engage with me on this level and became flustered. Do you notice that too?” By keeping my process comment at a basic descriptive level. U talked about loaning money to his younger daughter. U’s feelings. condemning. U had considerable difficulty expressing his anger. In keeping with the goal of wanting to promote his taking risks in letting people know his wants and needs directly. I commented on the process (“Seems like this is a difficult question. In response. that he feared that I would be displeased. Not unexpectedly. I did not chastise him (e.g. Later in the session.. I interpreted that he was more comfortable talking about his physical feelings than his emotional ones. This afforded me the opportunity to ask Mr. I was inviting Mr. Mr. interpret his withholding). allying with the resistance). I became more interested in his manner of interacting with me—in this case. In response.”). Instead.”). I asked him to communicate in a way that was familiar to him. he was able to say that his feelings were hidden. As a way to help him tune into what he did feel. U: “I notice that when I ask you these kinds of questions. U to explore the reasons he might go through life not acknowledging what he felt. I explained why people might keep feelings hidden. Mr. even from themselves. This money allowed her to live separately from him—something I knew from the second session that he did not want (“I just want her in the same household. how he subverted showing anger. His response (“I’m so constipated. U’s cyclical maladaptive pattern.e. However.182 The Art and Science of Brief Psychotherapies In the fourth session. based on Mr. Given that he often somaticized his emotional pain. I shared an observation with Mr. Mr. U replied in a stuttering voice that he wanted to keep his feelings hidden and not talk about them. . U to claim that his feelings were unknown to him. U how he felt about loaning her money. After attempting to reveal Mr.”) was relevant on two levels—literally (I am physiologically blocked) and symbolically (I am psychologically blocked). I asked him to concentrate on his bodily sensations. I decided to raise the issue of a “good reason” because I suspected.. Although I was still interested in Mr. I then asked him if there might be a good reason to keep the feelings hidden from his point of view (i. with the intent of determining whether he could express some of his more negative feelings as a way for him to feel more empowered and entitled. With more probing. This led Mr.

Mr. Mr. U’s dependency needs and his comfort with my taking control. However. I broached the possibility of using these techniques in a low-key. allowing him to be more compassionate with himself for his “failure” to protect his mother. the use of such techniques did not appear to jar Mr. Mr. The TLDP therapist needs to attend to the current relational context for judging the appropriateness as well as the effectiveness of any intervention. The critical question is whether the interven- . I was also ready to process their use should Mr. Throughout the rest of the therapy. it is not just the introduction of techniques from other schools that requires such careful monitoring. this seemed like a big step for Mr. I used behavioral rehearsal (for him to feel what it might be like to assert his needs in an anticipated new living situation) and the gestalt empty-chair technique (for him to talk to himself as a boy). U again complained that he was constipated. I remained focused on the goals for the treatment. I felt free to use various interventions that might facilitate his feeling more assertive and empowered and less passive. it would not have made much difference if he took the stool softener immediately or when our session ended. U was accustomed to my using a variety of pragmatically designed strategies. In the previous session. lending to their coherence (i.” I was encouraged by Mr. However. I conveyed to him I would be open to changing the subject if he wished. You’re saying that you want to keep the feelings hidden. phenomenologically they made sense). Here was another opportunity in the therapy for him to have a different experience of himself and me. Given the brevity of the therapy.e. Furthermore.Time-Limited Dynamic Psychotherapy 183 I underscored what he had said (“I think you are saying something very important. Rather than interpreting what I thought was going on. his saying that he wanted to leave early appeared to be an unconscious test to see if I really would “let him go. because the interventions were all designed to achieve one major goal. Following this interchange. Toward the end of this session. it is important to note that because of Mr. Mr. In this session. He mentioned that he had a stool softener in his car and said that he would like to leave the session early to take it. In this particular case. I simply told him that I would look forward to seeing him at our usual time next week. For example. However.”). U had decided not to leave to get something to eat.. U. U’s reaction be untoward or result in a reenactment of his cyclical maladaptive pattern. collaborative way. subjectively. U—to put forth his needs despite his expectation that they might conflict with my desire to have him remain in the session. U’s direct statement of what he wanted to do. U. From a physiological standpoint. they had a common theme.

Can you say to me. 51). but shaky.” They indicated that “it is important to help clients truly know that they can choose to say ‘no. Mr. 50). I don’t want to answer that question right now?’” (p. (1996) described a gestalt technique of encouraging the client to “say no.4 4 For a session-by-session commentary. . the use of such an intervention would have been counterproductive. so he was happier and further encouraged to be more independent in his life. see Levenson 1998. they indicated that the therapist should state to a client who was saying no indirectly.184 The Art and Science of Brief Psychotherapies tion has potential for promoting the idiosyncratically defined new experience. for Mr. As an example of this technique. patients’ experiences in brief therapy help disconfirm their ingrained dysfunctional interpersonal expectations and alter their internalized views of self and others. In Mr. placating. However. Mr. Glickhauf-Hughes et al. The opportunity for disconfirming his own pathogenic beliefs would have been lost (Weiss and Sampson 1986). U. his children experienced him as more delightful to be around and consequently involved him more in their lives. and resentful. Termination Mr. This was what Mr. U’s 1-year and 6-year follow-up. including a videotaped portrayal of this case and information on Mr. he took risks to be more assertive with me in the therapy. Such continued therapeutic work is at the crux of TLDP because a brief treatment usually only helps the patient to start moving in the desired direction and does not take him or her to the final destination. This encourages them to try out new. In this way. “My hunch is that you really didn’t want to answer that question. he might have submissively followed my instructions to say no or learned that such “assertive behaviors” would please me. As a result. U’s case. U began our last session by relating how his children were visiting more and inviting him to do things. U would not have had to risk my disapproval if he said no and therefore would not have had the full experience of confronting me. In either case. His improved relationships with them illustrate the chief principle whereby TLDP is thought to generalize. ‘No.’ even to suggestions by the therapist” (p. Ideally. U wanted in the first place. even though the sessions with me would be coming to a close. behaviors with other people. U would be expected to be able to continue his therapeutic work in his naturalistic environment. His increased confidence in his abilities to get his own needs met led him to be less anxious.

New York. I discussed criteria for patient selection along with case formulation guidelines. Overstreet D: Outcome and follow-up data from the VAST Project. BC. 1973 Fisher S. Vol 2: Separation. Canada. 1997 Glickhauf-Hughes C. 1994 Hartmann K. Psychotherapy 31:49–57. Basic Books. Edited by Crits-Christoph P. 1996 Harrist RS. in Handbook of Short-Term Dynamic Psychotherapy. New York. Levenson H: Case formulation in TLDP.Time-Limited Dynamic Psychotherapy 185 Summary In this chapter. Presentation at the annual international meeting of the Society for Psychotherapy Research. French TM: Psychoanalytic Therapy: Principles and Applications. New York. Basic Books. Finally. New York. Edited by Bergin AE. June 1995 Henry WP. I presented an overview of TLDP. England. Wiley. References Alexander F. York. Vancouver. Gaston L: Psychodynamic approaches. New York. New York. strategies for treatment interventions. 1987 Levenson H: Time-Limited Dynamic Psychotherapy: A Guide to Clinical Practice. Paper presented at the annual international meeting of the Society for Psychotherapy Research. 1994. Quintana SM. June 1994 Binder JL. 1991. followed by a discussion of the treatment’s goals (which focus on new experiences and new understandings). in Handbook of Psychotherapy and Behavior Change. Basic assumptions of the TLDP model were reviewed. 1995 . pp 137–165 Bowlby J: Attachment and Loss. The approach stresses the importance of the therapy relationship as a vital factor in eliciting and changing maladaptive interpersonal modes of behavior and personality patterns. and Anger. Clance PR. Anxiety. 2nd Edition. Strupp HH. 1946 Bein E. and an illustrative case. Ronald Press. Wiley. New York. Strupp HH. Journal of Psychotherapy Integration 6:39–59. Plenum. Barber JP. Garfield SL. Strupp HH: The Vanderbilt approach to time-limited dynamic psychotherapy. The approach shows that meaningful changes can be obtained with a relatively brief treatment format based on a psychodynamic framework. Levenson H. pp 467–508 Horowitz M: States of Mind: Analysis of Change in Psychotherapy. which stems from traditional psychoanalytic theory and therapy roots but has an effective approach with a different emphasis than that of classical psychoanalysis. Greenberg RP: Freud Scientifically Reappraised: Testing the Theories and Therapy. et al: Internalization of interpersonal process in time-limited dynamic psychotherapy. Basic Books. Reviere SL. et al: An integration of object relations theory with gestalt techniques to promote structuralization of the self.

pp 1151–1176 Luborsky L: Principles of Psychoanalytic Psychotherapy: A Manual for Supportive-Expressive Treatment. 1999 Levenson H. Bein E. Yudofsky SC. New York. 1999 Stern D: The Interpersonal World of the Infant. 1995 Siegel DJ: The Developing Mind: Toward a Neurobiology of Interpersonal Experience. New York. Washington. 1990 Safran P. New York. New York. Henry WP: Modeling recurrent relationship patterns with structural analysis of social behavior: the SASB-CMP. Pinsof NM. et al: Concise Guide to Brief Dynamic and Interpersonal Psychotherapy. 1985 Strupp HH. Strupp HH: Recommendations for the future of training in brief dynamic psychotherapy. 1953 Travis LA. June 1993 Levenson H. Powers T. New York. Weiss J: Testing hypotheses: the approach of the Mount Zion Psychotherapy Research Group. et al: Changes in clients’ attachment styles over the course of time-limited dynamic psychotherapy. Binder JL. 1984 Messer SB. Guilford. 2002b. PA. Basic Books. Basic Books. Bliwise NG. 1998 Levenson H. Warren CS: Models of Brief Psychodynamic Therapy: A Comparative Approach. DC. Segal ZV: Interpersonal Process in Cognitive Therapy. pp 1151–1176 Levenson H. in Handbook of Psychotherapy Case Formulation. 1986. San Francisco. pp 591–614 Schacht TE. J Couns Psychol 37:123–130. 1984 Sullivan HS: The Interpersonal Theory of Psychiatry. New York. 2001 Wachtel PL: Action and Insight. 2002a. Levenson Institute for Training. Psychotherapy Research 4:208– 221. Butler SF. pp 84–115 Levenson H. New York. Basic Books. CA. New York. Paper presented at the annual international meeting of the Society for Psychotherapy Research. Strupp HH: Cyclical maladaptive patterns in time-limited dynamic psychotherapy. Butler SF. Bein E: VA Short-Term Psychotherapy Research Project: outcome. Guilford.186 The Art and Science of Brief Psychotherapies Levenson H: Time-Limited Dynamic Psychotherapy: Making Every Session Count: Video and Viewer’s Manual. Pittsburgh. 1997. Psychotherapy 38:149– 159. Edited by Eells TD. 4th Edition. in The Psychotherapeutic Process: A Research Handbook. American Psychiatric Publishing. et al: Brief dynamic individual psychotherapy. Edited by Greenberg LS. Edited by Hales RE. WW Norton. Meara NM: Internalization of the therapeutic relationship in short term psychotherapy. New York. Basic Books. 1995 Quintana SM. New York. 1987 . in The American Psychiatric Publishing Textbook of Clinical Psychiatry. American Psychiatric Publishing. Washington. Binder JL: Psychotherapy in a New Key: A Guide to Time-Limited Dynamic Psychotherapy. Guilford. Guilford. Guilford. 1990 Sampson H. DC. J Clin Psychol 55:385–391.

DC. Goldfried MR. New York. New York. American Psychological Association. and the Relational World. Clinical Observation and Empirical Research. Edited by Norcross JC. 1992. 1997 Wachtel PL. in Handbook of Psychotherapy Integration.Time-Limited Dynamic Psychotherapy 187 Wachtel PL: Psychoanalysis. Basic Books. Sampson H: The Psychoanalytic Process: Theory. Guilford. 1986 . McKinney MK: Cyclical psychodynamics and integrative psychodynamic therapy. pp 335–372 Weiss J. Behavior Therapy. Washington.

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A. the term couple therapy is used to recognize that many couples who are not legally married have problems and are assisted by these intervention strategies. Ph.D. everal different theoretical approaches use a brief therapy format to assist couples who are experiencing relationship distress.1 A fourth approach—integrative behavioral couple therapy (Christensen et al. Sullivan. Three of these approaches—cognitive-behavioral couple therapy (Epstein and Baucom 2002). although the empirical findings for this approach are still being analyzed S 1 Although almost all of the empirical treatment research has been conducted with married couples. Norman B. in this chapter. emotion-focused couple therapy (Johnson and Greenberg 1995). Ph. 1995)—appears to be equally efficacious. Epstein. 189 .D. Baucom.7 Brief Couple Therapy Donald H. M. Laura J. and insight-oriented couple therapy (Snyder and Wills 1989)—have empirical support indicating their efficacy in working with maritally distressed couples.

weakened. Although learning skills is beneficial to many distressed couples. 1998 for a detailed description of the empirical status of various forms of couple therapy). A traditional behavioral model assumes that the behavior of both partners is shaped. which dates back to the 1970s..” the latter implying that a couple who has a dysfunctional interaction pattern has the ability to perform more constructive skills but fails to do so for some reason. Cognitions. 1993. because they have not developed or maintained the skills necessary to meet the demands of an ongoing relationship. influential events outside the relationship (e. In addition. the focus of this chapter. As a result. 2003). meeting another very appealing person) affect the partner’s tendency to remain in the relationship as well as his or her subjective feelings of satisfaction (Jacobson and Margolin 1979). Several principles characterize the theoretical and treatment strategies used in the early forms of behavioral couple therapy. heavy emphasis was placed on teaching couples the skills necessary for the performance of relationship roles and functions. In traditional behavioral couple therapy. has documented evidence of its effectiveness. particularly those events involving the other partner. Behavioral couple therapy also is based on an assumption that couples are distressed. Cognitive-behavioral couple therapy. improvements in relationship adjustment across a broad range of couples cannot be accounted for by improvement in communication skills alone (Halford et al. strengthened. In addition. as well as skills necessary to make behavioral changes and communicate constructively. A great deal of research and clinical experience confirm that distressed couples typically express much more negative behavior and much less positive behavior than do nondistressed couples (Epstein and Baucom 2002). compari- . and Emotions Cognitive-behavioral couple therapy has evolved over several decades and owes its origins to more strictly behavioral approaches to understanding relationship distress. such as a choice to behave negatively in order to retaliate for a partner’s negative actions. and modified by environmental events.190 The Art and Science of Brief Psychotherapies (see Baucom et al. Difficulties with such skills are presumed to result from a “skills deficit” or a “performance deficit. in part. These include skills for making decisions. marital satisfaction is viewed as a function of the ratio of rewards derived to costs incurred from being in the marriage. in approximately 20 controlled investigations on several different continents (Baucom et al. Iverson and Baucom 1990).g. Theoretical Background Behaviors.

whereby cognitive appraisals of the events are either distorted or extreme (e. Thus. Often partners fail to recognize that their thinking has become distorted or extreme and. instead.g. 1998. a major task of the cognitive-behavioral couple therapist is to help couples become more active observers and evaluators of their own automatic cognitions (e.. 1979). As cognitive models of individual psychopathology brought attention to the important role of cognitive factors in clinical phenomena (Beck et al.g..”). the partners’ thinking maintains and exacerbates the relationship distress.. Because these distorted thoughts are almost always skewed in the negative direction in distressed relationships.Brief Couple Therapy 191 sons of behavioral couple therapy with other treatment approaches that do not emphasize behavioral skills training have found these other treatment approaches to be equally efficacious in alleviating distress. Although altering the ways that partners behave toward each other and think about their relationship can at times change significantly their . attributions) and their longstanding assumptions and standards about their relationship. stream-of-consciousness thoughts or automatic cognitions as absolute truth.g. you’d want to spend all your free time with me. not with your friends. indicating that skills training may not be necessary or sufficient for positive treatment outcomes (Baucom et al. That’s what a marriage should be. your friends. marital researchers focused on cognitive variables as a critical element in understanding the relationship between couple behavior and marital distress (Baucom et al. Consequently. 2000). Football. 1995). Cognitivebehavioral approaches assume that altering the information processing and cognitions in partners who have notable distorted or extreme cognitions subsequently will lead to positive changes in emotions and behaviors (Epstein and Baucom 2002). A major premise of this approach is that some partners’ dysfunctional emotional and behavioral responses to relationship events are influenced by inappropriate information processing. The combination of these findings suggests that a behavioral skills deficit model is too narrow to explain or treat couple distress and highlights the need to attend not only to partners’ behavior but also individuals’ interpretations and evaluations of their own and each other’s behavior (Baucom and Epstein 1990). cognitive-behavioral couple therapy evolved from the gradual expansion of behavioral couple therapy and its treatment strategies to include a focus on cognitive factors in the onset and treatment of couple distress. trust their own subjective.”) or are evaluated according to extreme or unreasonable standards of what a relationship should be (e. “You went to the football game with your friends and stayed out late because you don’t really love me. and everything else in life are more important to you than I am. “If you really loved me.

differentiating among emotions. the Couple. The Individual. experiencing certain emotions as dangerous or unacceptable. Epstein and Baucom (2002) proposed that relationship difficulties can result from factors at three different levels: the individual. well-adjusted partners can experience relationship distress if what they want or need . and having skills to express these emotions to one’s partner. At the other end of the continuum. The partners of these individuals who struggle in the emotional realm often experience them as intellectual. some individuals have difficulty containing their emotions and express them in an unmodulated. and the Environment A healthy relationship is one in which the relationship contributes to the growth and well-being of both partners as individuals. in which their emotions are easily aroused. destructive manner. one or both partners’ emotions are of central importance and serve as the focus for intervention. the two partners work well together as a unit or team. This could include problems in being aware of emotions. experiencing. At one end of the continuum. Individual Factors On an individual level. but this explanation is too narrow as a way to understand the numerous factors that contribute to relationship discord. even two psychologically healthy. in some important instances. Often. they experience emotional dysregulation. Partners of such individuals often report that they must “walk on eggshells” so as not to upset the person. and emotions typical of distressed couples can be explained partially as a skills or performance deficit. Cognitive-behavioral couple therapists must attend to important emotional factors at both ends of the continuum to be of assistance to a broad range of couples. Relationship distress can result from difficulties in any or all of these domains. and the environment. and/or distant. some individuals have difficulty accessing. This emotional dysregulation can lead to destructive behaviors that are focused on the individual himself or herself or are directed at the partner. are experienced at a high level. cognitions. and are slow to return to a more reasonable level (Linehan 1993). relating emotional experience to internal and external events. and the couple relates to their broader environment in an adaptive fashion—contributing to their social and physical environment and using environmental resources for the well-being of the couple. The negative behaviors. unemotional. and/or expressing emotions.192 The Art and Science of Brief Psychotherapies feelings toward each other. the relationship.

This withdrawal then leads to greater attempts at closeness from the first partner. and behaving negatively toward each other as they attempt to get their needs met. getting mired in a demand/withdraw pattern can be a secondary source of distress in response to the partners’ differing needs for intimacy. and 4) the need to be attended to by one’s partner. this often leads to relationship distress. distorting their interpretations of the partner’s behavior. these secondary sources of distress take on a life of their own. The individual who seeks more closeness often will approach the partner. partners can differ in their needs for autonomy. who. and less planful.Brief Couple Therapy 193 from their relationship differs. organization. when people do not get their important needs and desires met in their relationship. 3) the desire to be altruistic or give to one’s partner. In addition. 2) the need for intimacy or closeness with one’s partner. control. and these differences can spell problems for many couples. a secondary source of distress. such as 1) the need to affiliate or be part of various groups. In both of the examples above. Epstein and Baucom enumerated the important needs and motives that often become problematic in couples’ relationships. Partners also have individually focused needs that can serve as a source of relationship distress. These include important relationship-focused needs. then withdraws. when two partners differ in the amount of closeness and intimacy they desire or the ways in which that intimacy is to be expressed. the two partners can experience daily frustrations in their attempts to reconcile their different tendencies and live harmoniously as a couple. and achievement. this can be the primary basis of their dissatisfaction with the relationship. over time. they often respond in destructive ways to not getting their needs met. That is. with corresponding greater withdrawal from the second partner. For example. one partner with a high need for control might want to keep the home environment well organized and engage in detailed planning on a regular basis. For example. Often. and planning might respond to their frustrations by becoming emotionally upset. and the cognitive-behavioral couple therapist must be responsive to both primary and secondary distress. For example. desiring more distance. including a couple relationship. Elsewhere (Epstein and Baucom 2002). If this individual is married to someone who is more relaxed. partners who differ in their desire for intimacy or in their personal preferences for control. we differentiated between primary distress associated with partners’ experiences of unresolved differences and unmet needs and secondary distress associated with partners’ dysfunctional ways of interacting in response to those unresolved issues. spontaneous. this pattern can evolve into a demand/withdraw pattern that characterizes many distressed relationships. That is. such as differing desires for intimacy and the .

healthy individual differences is an important part of couple therapy. Such couples often seek assistance from therapists because of a lack of vitality or sense of disengagement in their relationship. a personality disorder. this can be a highly rewarding interaction pattern. the therapeutic context becomes increasingly complex if one or both partners have significant individual psychiatric problems. in which both partners are highly involved in the interaction. they exist in a broader social and physical environment that includes their families. some couples engage in a demand/withdraw pattern in which one partner pushes for engagement and the other partner attempts to distance. some couples have a mutual avoidance or withdrawal pattern. Second. in which both partners maintain significant distance. unless the couple is discussing a topic of particular importance to the man. in the context of poor communication skills or negative emotions. and helping them develop more constructive ways to interact with each other. Although it is beyond the scope of the current chapter. Couple Factors A relationship is more than the sum of the two individuals involved. Third. These patterns have been noted for many years and have been particularly well documented in the research of Christensen and his colleagues (Christensen and Heavey 1993). If the two partners engage in constructive behaviors and communication while interacting. However. unresolved individual issues. Cognitive-behavioral couple therapy assists couples in recognizing these maladaptive interaction patterns. mutual engagement can involve frequent and destructive arguments and fights. Elsewhere. a couple might show mutual engagement. Environmental Factors Couples do not live in isolation. Important interactive patterns can contribute to relationship discord and can serve as the focus of cognitive-behavioral couple therapy.194 The Art and Science of Brief Psychotherapies demand/withdraw pattern that the couple has developed. Thus. we described how to integrate the treatment of relationship distress and individual psychopathology in a couple context (Epstein and Baucom 2002). and the most typical pattern is for the woman to assume the demanding role and for the man to assume the withdrawing role. communities. rather. understanding the basis of these patterns. broader . First. as described earlier. helping partners to understand and find ways to negotiate normal. or long-term. This pattern is particularly common among distressed couples. it takes on a unique character that typifies the relationship itself.

with a wide range of subsequent stresses. expectations. the beginning therapist can feel overwhelmed by the large number of issues with which a distressed couple presents and not know how to proceed. a couple will show their central difficulties multiple times to a therapist. Similarly. it is important for the therapist and couple to agree on the important foci for treatment and maintain these foci. Often these environmental factors outside of the couple exert demands on the couple to adapt. In most instances. For example. distressed couples are responding to these individual differences in maladaptive ways. Focus of Therapy In order for a couple to make progress in a brief therapy context. including practical support (e. both couples and therapists overlook or minimize the role of external stressors.g. the therapist helps the couple recognize these differences. which serves as the basis of their maladaptive interaction patterns. demanding and withdrawing). dealing with in-laws and the partners’ families of origin can be a major source of difficulty for partners as they try to navigate different family rituals.. and roles.. and environment. helps them stop their maladaptive ways of interacting around these issues (e. leading to communication training as described later in this chapter (see “Skills-Based Interventions”). economic downturns can result in partners being unemployed or underemployed. at times beyond the couple’s capabilities.g. which can interfere significantly with optimal relationship functioning. These themes can be organized into the domains described earlier: individuals. Typically. On the other hand. leading to interventions focused on helping the couple change the environment where possible. babysitters) and emotional support. There is no algorithm for deciding what the major themes are for a couple. the environment can provide important resources for the couple. At times. the therapist might conclude that the couple’s major difficulty centers around individual differences in their needs for intimacy or the degree to which they are achievement oriented in approaching careers.Brief Couple Therapy 195 institutions. and searches for more adaptive ways to address these individual differences. Therefore. support each other through the difficult times. For example. the therapist and couple might conclude that the couple lacks communication skills. the therapist can identify two or more major themes around which to develop an intervention plan. In most instances. and seek outside support when appropriate. Or it might be determined that the couple is responding to overwhelming environmental stressors. couple interaction. Often. and cultures. Similarly. and the major themes are seen in .

the therapist wants the couple to experience success in their efforts to improve their relationship. particularly given that many distressed couples feel hopeless when they seek treatment. Second. As we noted earlier in the chapter. First. A hallmark of this approach is that it is focused on specific concerns and teaches couples to take control of their own difficulties by using the interventions learned during sessions in their everyday lives. many studies indicate that negative behaviors between partners prove to be particularly destructive and become the focus of a couple’s experiences (for a recent review. it is essential to consider individual factors. When several themes are present. Therefore. a hallmark of cognitive-behavioral couple therapy is its focus on specific behaviors. Elsewhere. at least two factors are of importance. the therapist should work diligently early in therapy to decrease highly aversive interactions between the partners. but it is critical to decrease destructive interactions early in treatment. and the environmental context within which the couple operates. The initial identification of presenting problems and the partners’ goals in seeking therapy . couple interactions. the therapist must decide what to address first. 1998). see Epstein and Baucom 2002). At the same time. to understand a couple’s functioning. treatment should begin with an area in which the couple can be successful and develop an increased sense of their ability to improve their relationship. Conducting a couple assessment involves several steps: 1. A careful and thoughtful understanding of these specifics can allow the therapist to organize them into broader themes. A brief description of the basic steps and strategies used in an initial assessment follows. In doing so. cognitions. Increasing positive interactions is important. the therapist and couple must identify a few major themes that are interfering with couple functioning or that detract from optimal relationship satisfaction. we wrote at length about how to conduct such an assessment (Epstein and Baucom 2002). A detailed consideration of conducting a couple assessment to evaluate these factors is beyond the scope of this chapter. and emotions within the couple’s relationship. Assessment of Couple Functioning To provide brief therapy for couples. Therefore. which can then be addressed in therapy.196 The Art and Science of Brief Psychotherapies various specific situations. Numerous investigations have found that brief cognitive-behavioral couple therapy is efficacious with distressed couples (Baucom et al.

attending to major themes. At this point in the assessment. emphasizing both relationship difficulties and relationship strengths. These might include long-term interaction patterns. often it is possible to identify significant themes in their relationship that serve as the focus for intervention. including observation of the couple’s interaction patterns 3. individual interviews with each partner are often helpful. and defending themselves. along with that individual’s perceptions of relative strengths within the relationship. blaming each other. During these interviews. and reasons for seeking couple therapy. Throughout the history. and attempt to develop a positive working relationship with each partner. couple. This detailed description of current concerns and relative strength from each partner can augment the therapist’s observations of the relationship history to round out important themes and the specific ways in which they are enacted within the relationship. such as partners mutually avoiding each other. it is valuable to place this into a historical context to understand how current concerns have developed. The therapist’s assessment feedback summary to the couple Typically.Brief Couple Therapy 197 2. Although there are varying perspectives among couple therapists. periods during which changes occurred in both a positive and a negative direction. obtain additional information about issues that arose during the couple’s joint assessment interview. or the couple not coping well with significant environmental stresses. the assessment begins with a joint interview with the couple. It is important during these individual inter- . and how the couple arrived at the current state of relationship functioning. the therapist attends to individual. the therapist can obtain an individual history for each person. only a brief amount of time is spent defining their concerns. A relationship history and assessment of current relationship functioning. each partner is given an opportunity to express his or her concerns. With both people present. with a brief description of their current concerns. An individual history and assessment of current functioning of each partner 4. problems. As a couple describes their history. Consequently. Once the therapist has an overall understanding of the couple’s concerns. the therapist conducts a rather detailed history of the couple’s relationship. and environmental factors that have contributed to relationship distress. the assessment returns to a fuller consideration of current relationship functioning. lest couples deteriorate into protracted arguments. Once the couple has completed a relationship history. one person needing a greater degree of intimacy than the other individual.

and behavioral observations of the couple’s interactions. Continuing with an earlier example. couple. These conversations include a discussion of positive thoughts and feelings that partners have toward each other. an understanding of each individual’s history and current functioning. the current focus involves asking the couple to engage in a series of conversations with each other to allow the therapist to observe the partners’ interacting without the therapist intervening. Once an agreed-on formulation of the couple’s relationship distress and related intervention strategies is reached. and environmental factors that contribute to relationship discord. Next. couple. the assessment involves direct observation of the couple’s interaction patterns.198 The Art and Science of Brief Psychotherapies views not to develop an allegiance with either partner to the detriment of the other member of the relationship. cognitive. the cognitive-behavioral couple therapist explores the relevant individual. Although a certain amount of this interaction has occurred during the previous assessment strategies. and emotional factors that must be addressed. During this feedback. attempts to provide support to one individual when that person expresses concerns not focal to the relationship. thus. pointing out the individual. These individual interviews can provide detailed information about how each partner contributes to relationship functioning. expression of their thoughts and feelings about relationship difficulties. the therapist develops an initial formulation and related treatment plan. as well as those that serve as resources. the therapist is attentive to important behavioral. their current concerns and strengths. In all of these domains. and how the therapist proposes to help the couple make appropriate changes. how they developed over time. This feedback and discussion are important to create a shared understanding of the goals of therapy and the strategies that will be used. The final step is to share these observations with the couple. and the couple’s ability to make decisions or solve problems when significant concerns are present in their relationship. Role of the Therapist Within the context of the earlier discussion. one should not hold secrets or collude with one individual. On the basis of these discussions of the couple’s relationship history. each partner provides his or her own perspectives on issues that the therapist has isolated. and environmental factors that appear to be important. if two partners differ in . along with additional areas that need to be addressed within the treatment. treatment begins.

Christensen and colleagues (in press) found that couples con- . the therapist might talk with them about various ways that couples can foster intimacy in their relationships by connecting verbally. For example. behavioral. A developmental and historical perspective on both individuals and the relationship is taken into account in understanding the couple’s current relationship distress. This role of educator also might involve helping the couple learn and apply new communication skills as they seek to be more open and disclosing with each other. the cognitive-behavioral couple therapist uses a wide variety of cognitive. Cognitive-behavioral couple therapy is predicated on the notion that couples must learn to enact their new ways of behaving. ranging from maintaining control over emotional expression for a couple who has strong and frequent emotional outbursts to creating opportunities for caring interactions between partners who have been distant from each other. thinking. the therapist helps couples decide on new strategies that they will use between sessions to help their new learning generalize to their everyday lives. and emotionally. Although the length of treatment varies as a function of the characteristics of the particular couple. A safe environment can be created in a variety of ways. as well as within sessions. the pursuer may become angry at being deprived of the closeness that he or she wants. following the agenda with a variety of behavioral. providing psychoeducation as needed. creating a safe environment within which the couple can address difficult issues. Recently. cognitive. behaviorally they might develop a demand/withdraw pattern. the therapist assumes the role of educator. physically. the role of the cognitive-behavioral couple therapist is similar to that of cognitive-behavioral therapists in other contexts—reviewing the couple’s homework since the last therapy session. the pursuer in the couple might think that he or she is unloved as the partner seeks greater distance. setting an agenda for the current session. most treatment outcome studies have reported between 8 and 26 therapy sessions. In essence. The therapist is also a facilitator. Cognitively. but the primary focus is on the couple’s current functioning and ways of responding more adaptively to each other in the future.Brief Couple Therapy 199 the degree of closeness and intimacy that they want from the relationship. as described below (see “Interventions for Modifying Behavior”). and guiding the couple in setting up new homework activities to be completed before the next session. In assisting the couple. At times. and feeling outside of therapy sessions. and emotional interventions during the session. and behaviorally and about how these principles might apply to their relationship. if a couple is seeking assistance because they both feel more distant from each other than they would like. Therefore. and emotional interventions.

but they fall into two major categories: guided behavior change and skills-based interventions (Epstein and Baucom 2002). In fact. It brings out the worst in me.200 The Art and Science of Brief Psychotherapies tinue to improve at a linear rate for approximately 26 sessions. “I can’t stand who I have become in this relationship. Asking each person to make appropriate changes and be responsible only for himself or herself helps to alleviate this “Who goes first?” mentality. for example. they cannot communicate well with each other. or they have lost the ability to have fun together. A notable number of others raise concerns about themselves.” In cognitive-behavioral couple therapy. Other individuals focus on problems of the couple as a unit. I don’t like being petty or nasty to another person. and this emphasis continues in our current conceptualization. these interventions have been referred to as behavior exchange interventions. 1994). their concerns take a variety of forms. Within this broader context. with complaints such as the partner being too hostile or negative or the partner not engaging in enough constructive or helpful behavior. Too often. and it gives each individual a sense of personal control in improving the relationship. distressed couples operate in a quid pro quo fashion in which each person is only willing to change contingent on the other person’s efforts. there has always been a strong emphasis on helping members of couples behave in more constructive ways with each other. gains appear to occur throughout treatment and not only in the early or late stages of intervention. for example. At times. Guided Behavior Change Guided behavior change involves interventions that focus on changing particular types of behavior without teaching partners specific skills. Interventions for Modifying Behavior Almost all distressed couples are unhappy with the way that they are behaving toward each other. often it is helpful for the therapist to discuss with the couple the importance of each person committing to make constructive behavior changes irrespective of the other person’s behavior (Halford et al. . The therapist might use any of the numerous available specific behavioral interventions with the couple. that is. but this term can be misleading because these interventions do not involve an explicit exchange of behaviors in a quid pro quo fashion. Many individuals are focused on the unacceptability of their partner’s behavior.

to help the dyadic relationship function effectively. these types of interventions are used when the therapist and couple conclude that the partners have stopped making much effort to behave in caring and loving ways toward each other. so that the relationship can bring out the best in you as an individual. a couple and therapist might decide that they need to change the overall emotional tone of the relationship. These interventions generally involve having each partner decide to engage in some positive behaviors intended to make the other person happier. we work together with couples to develop a series of decisions about how they want to make changes in their relationship to meet the needs of both people. First. Typically. have allowed themselves to become preoccupied with other life demands. your partner is likely to be much happier and to respond to you in a positive manner. and have treated their relationship as a low priority. you are likely to feel better about yourself. Instead. One hallmark of courtship is the great amount of time and effort that partners typically put into creating a positive relationship environment . or critical interactions take place. Many couples complain that it simply is no longer pleasant being around each other because the general tone of the relationship has become so dissatisfying. contracts) that were common in the early days of behavioral couple therapy (Jacobson and Margolin 1979). very few positive interactions occur between them. and an excess of negative. caring. these rather broad-based interventions are intended to help couples regain a sense of relating in a respectful. 1973) and “caring days” (Stuart 1980). These types of guided behavior changes can be implemented at two levels of specificity and for different reasons (Epstein and Baucom 2002). so they choose a broad-based. such as making a telephone call during the week to say hello.Brief Couple Therapy 201 We might introduce interventions of this type as follows: What I want each of you to do is to think about how you would behave if you were being the kind of partner that you truly want to be.g. such as making coffee in the morning. These include “love days” (Weiss et al. In essence. So. What does that mean that you would do and not do? If you behave in this manner. Thus. we rarely attempt to establish rule-governed behavior exchanges (e. thoughtful manner.. The selected behaviors might include small tasks or chores. Various interventions have been developed to shift this overall ratio of positives to negatives. and to interact positively with their environment. it likely will have two very positive consequences. or more direct caring and affectionate behaviors. Second. general guided behavior change strategy. hurtful. First. I want you to get back to being the kind of person that you enjoy being in this relationship.

Although no attempt is made in therapy to rekindle courtship on a long-term basis. it is important for each of you to take personal responsibility to try to make the relationship better. As we discussed. Writing down what you did might help you keep in mind your goal of increasing positive behavior. so you may need to experiment a bit with things that can serve as a reminder to you. the therapist uses a guided behavior change with Mr. When people are out of the habit of making special efforts. and Mrs. they are not intended to address long-term. general guided behavior changes are intended only to create a shift in atmosphere. Let me describe for you a somewhat structured way that many couples have found helpful to get back to a more positive way of interacting with each other. some people put up . V. it is reasonable to help couples reestablish an ongoing positive. it’s just that we’re out of the habit. irrespective of whether the other person follows through. caring atmosphere. so that these are the types of things that you could sustain over time. complex problems in the couple’s relationship. as life gets busy. as long as I can remember to do it. What I would recommend is that every day. Therapist: I can understand. V: I think it sounds OK. and that does happen. V to help them create a more positive tone in their relationship.202 The Art and Science of Brief Psychotherapies and making the other individual happy. so I can get a picture of what both of you are doing. Also. I would like each of you to write down the specific actions that you take each day to behave more positively toward your partner and bring the record with you to our next session. Therapist: Mr. I don’t even think about it. and as you said. So I’m mainly concerned that she will get upset if in a few days I forget to follow through with this. they might have good intentions. To get things back on track. one of the things that you have mentioned is that you both believe that you have gotten away from really making much of an effort to make each other happy and create a generally positive atmosphere in your home. and Mrs. each of you does at least one small. but it is hard to follow through. It is important to recognize that these broad-based. caring. I really don’t mind trying to be thoughtful to my wife. it might be helpful if you make a special effort to start treating each other in helpful and caring ways again. In the following example. For example. People try various things to remember. but I want each of you to do it independently. you might prepare breakfast for the other person or run an errand for your partner. or helpful act for the other person that you do not typically do. And I really do want you to keep it small. For example. How does that part sound to each of you? Mr. it is easy for everything else to take priority over your relationship. I believe that is very common among couples. Those are addressed through a variety of additional interventions described later in this chapter. Both of you will be doing this.

I call it “Find your partner doing something nice. As a result of the initial assessment. and they don’t need to continue using this much structure. W. and I don’t think I’ll have any trouble remembering to do nice things for my husband. it is just as important to acknowledge as it is to give. what are your reactions to what I’m proposing that the two of you do? Mrs. life can start to feel routine. it is understandable that after 23 years. they find it rewarding. the therapist responds to the couple’s major complaint that after being married for 23 years. Let’s start to think about what you might do to create a greater sense of closeness with each other. and I could have it pop up a reminder at the beginning of each day. taking a class and discussing their per- . V: I think it sounds good. and Mrs. Once most couples begin doing this regularly. joking around and being silly. isn’t it? Therapist: It is in a way. Some couples find that they experience a sense of closeness when they talk with each other. Mrs. But that’s a pretty sad state of affairs when you need a reminder to do something nice for your partner. Therapist: Mr. In my opinion. isn’t it? And this is not something I’d recommend that you do forever. What is hard for me is that he does not seem to notice it.Brief Couple Therapy 203 sticky notes to remind themselves.” People do get discouraged and quit trying if they don’t believe that their partner notices or appreciates what they are doing. Therapist: I’m glad you mentioned that. disclosing inner thoughts and feelings is one of the most effective ways to increase intimacy between two people. without much of a sense of closeness or excitement. Do you have any ideas of what might work for you? Mr. In fact. How do each of you do in terms of expressing appreciation or acknowledging what the other person does? Guided behavior changes also can be used in a more focal manner. it really varies from individual to individual and from couple to couple. or set alarms on their watches. There is actually a second part to what I’m proposing that you do. sharing their thoughts and feelings about a variety of things. V. I do that fairly often already. write reminders in their calendars. V: I hadn’t thought about that. and then I’m not very motivated to continue doing it. In the following excerpt. and thank him or her for it. Some people feel close to their partners when they are having fun together. It really is a way to help you make some changes and break some old habits that you have gotten into. they no longer feel close to each other. Other people feel close to each other when they’re learning together. They rarely argue. the therapist and couple focus on important issues and themes that serve as the basis of the couple’s relationship distress. Therefore. But that is not the only way to develop a sense of closeness. There is no single thing that people do to feel close to each other. but I do have one of these digital organizers. but there is little vitality in their marriage.

Also. solving a problem. with the specific goal of making a decision.. both reading books. I know couples who feel close to each other when they sit quietly together in a room. Guidelines for these two types of communication are provided in Tables 7–1 and 7–2. The label skills-based interventions suggests that it is assumed that the partners lack the knowledge or skill to communicate constructively and effectively with each other. many individuals report that they communicate better with other people than with their partners. skills-based interventions typically involve the therapist’s use of didactic discussions and/or media (e. And other people feel close when they’re giving back to others outside of their relationship. We often differentiate between two major goals of communication between partners: conversations focused on sharing thoughts and feelings and decision-making or problem-solving conversations (Baucom and Epstein 1990. perhaps working on a joint task around the house. . what are ways that you have interacted with each other in the past that helped you to feel close to each other? Do any of the other ways that I mentioned sound appealing. Other people have a sense of closeness when they are out together enjoying nature. Conversations can be about daily activities or important topics regarding the couple’s life goals. In contrast.g. working together in a soup kitchen or volunteering for an environmental cause. or resolving a conflict. self-help books and videotapes) to instruct the couple in the use of particular behavioral skills. but as frustrations mounted. These guidelines are presented as recommendations. Some couples feel close when they are functioning well as a team. Many couples report that their communication was open and effective at earlier points in their relationship. they began communicating with each other in destructive ways. This instruction is followed by opportunities for the couple to practice behaving in the new ways. or they greatly decreased the amount of communication. Regardless of whether this is a skills deficit or a performance deficit. Epstein and Baucom 2002). decision-making conversations are much more goal directed. When you think about the two of you. even if you haven’t focused on them previously in your relationship? Skills-Based Interventions In contrast to guided behavior changes. In conversations for sharing thoughts and feelings. the purpose is for the partners to understand each other and have an opportunity to share their own perspectives. discussing guidelines for constructive communication can be helpful to couples in providing the structure they need to interact in constructive ways.204 The Art and Science of Brief Psychotherapies spectives on a variety of issues. although this often is not the case.

Speak in “paragraphs. conflicts. 2. Try to put yourself in your partner’s place. Table 7–1. then emphasizing the expression of emotion might be of primary importance. depending on the needs of specific couples.Brief Couple Therapy 205 not as rigid rules. While in the listener role. also include any positive feelings you have about the person or situation. the guidelines for expressiveness emphasize sharing both thoughts and emotions. Make your statement as specific as possible. When expressing negative emotions or concerns. in terms of both specific emotions and thoughts. Offer solutions or attempt to solve a problem if one exists e. state your feelings about your partner. desires. do not a. and look at the situation from his or her perspective to determine how the other person feels and thinks about the issue. except for clarification b. 6. as your own feelings and thoughts. not just your ideas.” That is. facial expressions. not what your partner thinks and feels. express one main idea with some elaboration and then allow your partner to respond. Interpret or change the meaning of your partner’s statements d. and posture. When talking about your partner. not just about an event or a situation. Show this acceptance through your tone of voice. 3. 4. speak for yourself. summarize and restate your partner’s most important feelings. not as absolute truths. The therapist can emphasize certain points and alter the guidelines. 5. Speaking for a long time without a break makes it hard for your partner to listen. 4. Ask questions. what you think and feel. Guidelines for couple discussions Skills for sharing thoughts and emotions 1. If the therapist is working with a couple who avoids emotions and addresses issues on a purely intellectual level. Make judgments or evaluate what your partner has said . After your partner finishes speaking. 2. 7. Express your emotions or feelings. Skills for listening to your partner Ways to respond while your partner is speaking 1. Express your own viewpoint or opinion c. State your views subjectively. Express your feelings and thoughts with tact and timing so that your partner can listen to what you are saying without becoming defensive. and thoughts. Show that you understand your partner’s statements and accept his or her right to have those thoughts and feelings. This is called a reflection. Also. Ways to respond after your partner finishes speaking 3. For example.

Break down large. a. because some couples easily can identify a mutually acceptable solution. Similarly. Clarify why the issue is important to you. a. c. then brainstorming might help the couple avoid their adversarial approach and each person’s premature . Do not accept a solution that will make you angry or resentful. Clearly and specifically state what the issue is. Do not dwell on the past or attempt to attribute blame for past difficulties. Do not accept a solution if you do not intend to follow through with it. a. c. b. specific solutions that take both people’s needs and preferences into account. specific. 2. agree to follow one person’s preferences. a. b. Make certain that both people agree on the statement of the problem and are willing to discuss it. Clarify why the issue is important and what your needs are. If a compromise is not possible. if a couple’s typical pattern involves each partner presenting his or her own preferred solution. followed by the couple arguing over the two proposals. Focus on solutions for the present and the future. Review the solution at the end of the trial period. 5. State your solution in clear. However. behavioral terms. c. consider brainstorming (generating a variety of possible solutions in a creative way).206 The Art and Science of Brief Psychotherapies Table 7–2. 3. during decision-making conversations. suggest a compromise solution. have one partner restate the solution. complex problems into several smaller problems. Propose concrete. Select a trial period to implement the solution if the situation will occur more than once. Phrase the issue in terms of behaviors that are currently occurring or not occurring or in terms of what needs to be decided. Explain what your needs are that you would like to see taken into account in the solution. Decide on a solution that is feasible and agreeable to both of you. After agreeing on a solution. b. Allow for several attempts of the new solution. a. If you cannot find a solution that pleases both partners. c. b. b. If you tend to focus on a single or a limited number of alternatives. we do not ask routinely that all couples brainstorm a variety of alternative solutions before discussing each one. do not offer specific solutions at this time. 4. and deal with them one at a time. taking into account what you have learned thus far. Revise the solution if needed. e. Discuss possible solutions. d. Do not focus on solutions that meet only your individual needs. Guidelines for decision-making conversations 1. and provide your understanding of the issues involved.

Mr. let’s try to stay attentive to one of the patterns that we have been picking up in your previous conversations. I think that’s basically it. Once they have agreed on a solution. In the following dialogue. X know if you see it in the same way. So tonight. Both my husband and I really enjoy being with our own families. Mrs. Other couples reach solutions more readily but they rarely implement their agreements. X: I think that the issue is that we have been married for 3 years and still haven’t figured out how to spend holidays like Thanksgiving. For some couples. As a result. Likewise. when you both understand what is important to each of you. some attention is given to implementing the agreed-on solution. you stated how you view the concern nicely. Therapist: Mrs. Mr. and if not. Both families would want us to spend all our time with them if we could. you reach a stalemate. Then. If that is OK. I think the problem is that we don’t have any good way for making this decision of where to go for . I recommend that you come up with some possible strategies that explicitly take both of your desires and needs into account. how you understand the current problem that the two of you are having. X: Well. as well as ways that both people can be reminded about the actions that they agreed to take during the week. reaching a mutually agreed-on solution is the difficult task. and I think we end up trying to convince each other or make each other feel guilty for wanting to spend time with our own families. without blaming either of you. and obviously. the couple might problem solve strategies to increase the likelihood that a solution will be implemented. we can’t do that because they live in different places. they are effective in carrying it out. in the decision-making guidelines. would you like to spend some time trying to make decisions about how to spend the Thanksgiving holiday this year? And as you work on this. In fact. If a couple has difficulty carrying out what they agree to do.Brief Couple Therapy 207 commitment to a particular solution. and Mrs. You both have a tendency to propose the solution that is ideal for you as an individual. and then you lock horns trying to convince each other to accept your own position. when you both share what is important to you about the holiday and spending time with families. I’d like you to start by clarifying the issue that you are facing regarding the holiday. why don’t you continue to focus on the statement of the concern and let Mrs. discussing possible barriers to following through. let’s be particularly aware of the second stage in the decision-making process. X. So I think the problem is that we do not have a good approach for deciding how to spend the Thanksgiving holiday with our two families. then the therapist can pay more attention to helping them implement their solutions more effectively. the therapist works with Mr. X. X as they attempt to make decisions about how to spend their holiday time with their families: Therapist: Good.

Honey. and I think that what he is saying is pretty much on target in terms of what I’ve told him. during skills training. In earlier approaches to . The guidelines for conversations devoted to sharing thoughts and emotions and conversations for decision making both focus primarily on the process of communicating. X’s emotions and preferences. you also did a nice job of clarifying how you see the problem. X thinks and says. have said these things to Mr. I think it is complicated by the fact that you are an only child. You did spend a fair amount of time talking about what Mrs. and I resent that. I really want to speak for myself. and I have three siblings who are married. Don’t propose specific solutions yet. X. I know that we can’t spend all Thanksgivings with them. if a lack of intimacy is a major theme in a couple’s problem. Mrs. My parents always have one or two of my siblings at their home for holidays. when the couple has expressive conversations. in which you both clarify what is important to you and what you prefer. But in this case. if you both feel that you have a common understanding of this concern about how to decide where to spend Thanksgiving. let’s move to the next step. but it feels horrible talking to them and telling them that there are 20 people gathering at your parents’ house for this festive occasion when they will be all alone. Mrs. In general. and we both end up feeling frustrated and hurt in the process. X in the past. or else they would be alone. are making inferences about Mrs. you seem to think that we should spend most holidays at your house. Mrs. X. You seem to feel that we should spend most holidays with your parents. Mr. with no particular attention to the content of topics that are discussed. In essence. Based on what you have said in the past. For example. be careful when speaking for the other person. we have discussed this many times. just share your thoughts and emotions about why this is important to you and what you believe needs to be taken into account in developing a good solution. However. Therapist: Fine. the therapist should attend to both the process of communication and how the couple addresses important content themes and issues in their relationship. such as discussing more personal feelings with each other. These major themes and issues should be taken into account while the couple engages in both types of conversations. it also is important for the therapist and couple to develop a joint conceptualization of the content of the primary themes or issues in the couple’s concerns. even if we’re not there.208 The Art and Science of Brief Psychotherapies Thanksgiving. they might emphasize ways of taking some chances to become more vulnerable with each other. and I think it should be 50–50. X: I do think that my husband has a general tendency to try to tell me what I think. X: The most critical thing for me is that my parents don’t end up feeling unloved or lonely over the holiday. or whether you. Therapist: Mr. X. I’m not sure if you.

If a given solution seems contrary to the changes that are needed to achieve the couple’s overall goals. and these meanings have a capacity to evoke strong positive and negative emotional responses in each person. if the members of a couple have expressed that they do not feel respected by each other. which the couple then could take into account in making their decisions. We believe that this is an important shift within cognitive-behavioral approaches. focusing on the communication process and attending little to the content of what the partners were discussing. attending to the content of the couple’s concerns. the therapist might question their proposal that they “take a break from each other” by spending more leisure time separately with their individual friends. therapists commonly restricted their role to being a coach. A therapist also can address the content of an issue during a couple’s decision-making conversation by providing educational information that will help to guide the couple in devising a solution. Interventions That Address Cognitions The ways that people behave toward each other in committed relationships have great subjective meaning for the participants. then the therapist might point this out and express concern about the solution. Thus. For him. As a result. Y grew up in a family where men showed their respect for women by opening car doors for them.Brief Couple Therapy 209 cognitive-behavioral couple therapy. For example. if a couple whose child has challenging behavior problems is discussing parenting issues. For example. individuals often have firm standards for how they believe the partners should behave toward each other in a variety of domains. that is how he believes he should show respect and love for his wife. providing a needed balance between addressing the couple’s communication and interaction processes and. If the standards are not met. and so forth. Mr. We believe that traditional cognitive-behavioral interventions can be used more effectively if the communication process and the important content themes in the couple’s relationship are addressed simultaneously. but it also could increase their sense of hopelessness that they will ever be able to discuss their different preferences in a way that makes them feel validated by each other. the therapist might provide them with information about parenting strategies that are most appropriate for their child’s developmental level. pulling up their chairs at a dinner table. the individual is likely to become displeased. On the . The therapist could note that this solution might temporarily help the couple avoid hurtful confrontations. at the same time. For example. the therapist might not always be a neutral party when a couple is proposing specific solutions to a problem.

Thus. people are people and should be treated the same regardless of gender. including • Selective attention—What each person notices about the partner and the relationship • Attributions—Causal and responsibility explanations for relationship events • Expectancies—Predictions of what will occur in the relationship in the future • Assumptions—What each believes people and relationships actually are like • Standards—What each believes people and relationships should be like These types of cognitions are important because they play roles in shaping how each individual experiences the relationship. Mrs. she is likely to experience his dinner preparation as positive. she had to make an extra effort among her male colleagues to be accepted as an equal. If she views this as his attempt to be thoughtful and loving. In essence. However. Y grew up in an environment in which such behaviors were seen as demeaning and patronizing to women. Mrs. as a lawyer. Y were in social gatherings with her colleagues. Y’s behavior as her being ashamed of him in social gatherings. but whether she interprets this as something positive or negative is likely to be influenced by her attribution for his behavior. As a result of their different standards for female and male role behavior. if she makes an inference that he has done something wrong and has made dinner in order to get in her good graces before telling her about it. an individual’s degree of satisfaction with a partner’s behavior can be influenced by the attributions or explanations that the individual makes for the partner’s behavior. a husband might prepare a nice dinner for his wife. In addition. and he interpreted Mrs. Y. Epstein and Baucom 2002). and not considering these cognitive factors can limit the effectiveness of treatment. they had frequent arguments and finally sought couple therapy. she did not want him to show traditional gender role behavior toward her that focused on her being a woman. Elsewhere. The therapist . she might feel manipulated and experience the same behavior as negative.210 The Art and Science of Brief Psychotherapies other hand. For Mr. we have enumerated and described empirical evidence about a variety of cognitive variables that can influence the quality of couples’ relationships (Baucom and Epstein 1990. When she and Mr. Y’s standard meant that he was not allowed to express his love and respect in a way that he felt that he should. partners’ behaviors in intimate relationships carry great meaning. For her. This was a major violation of her standards of egalitarianism and equality. Similarly.

both partners might have very realistic standards for how much time partners should spend together. • Identify macro-level patterns from cross-situational responses. the individual is likely to behave negatively toward the partner. A wide variety of “cognitive restructuring” intervention strategies can be used to assist distressed couples: • • • • • Evaluate experiences and logic supporting a cognition. Use the inductive “downward arrow” method (questions to tap underlying meanings of couple’s reactions). sometimes the focus of therapy will not be on changing behavior but will be on helping the couple reevaluate their cognitions about what is happening in their relationship. These various cognitive interventions can be categorized into two broad approaches: 1) Socratic questioning and 2) guided discovery. such cognitions are likely to be related to negative emotions. Although distorted or unrealistic cognitions of one or both partners often are the focus of cognitive assessment and intervention. Weigh advantages and disadvantages of a cognition. Consider worst and best possible outcomes of situations. an individual might selectively attend to instances when a partner is forgetful. Understandably. some couples experience relationship distress when both partners have realistic thoughts but they simply interpret or experience the world in different ways. and tapes. this same individual might attribute the partner’s failure to accomplish particular tasks as resulting from a lack of respect for the individual’s preferences and a clear reflection of a lack of love. readings. Epstein and Baucom (2002) provided a detailed description of each of these intervention strategies. • Identify macro-level patterns in past relationships. and under such circumstances. Provide educational mini-lectures. Instead. such as anger. so that these events can be viewed in a more reasonable and balanced fashion. the therapist is concerned if one or both partners seem to be processing information in a markedly distorted or unrealistic manner. the couple might struggle over their preferences for time together versus time alone. but if the standards are different. • Increase relationship-schematic thinking by pointing out repetitive cycles in the couple interaction. For example. Similarly. . Thus. Therefore.Brief Couple Therapy 211 does not attempt to have the partners reassess their cognitions simply because they are negative. paying little attention to other ways in which the partner accomplishes various tasks successfully.

you interpret it and give it meaning. the individual is more likely to be defensive and unwilling to acknowledge that his or her thinking has been selective or biased to some degree against the other person. In individual therapy. That meaning often is what determines your satisfaction and feelings at the moment. In working with distressed couples. Z. but that really is how it seems.” and he doesn’t want to embarrass himself in front of a therapist. In this case.212 The Art and Science of Brief Psychotherapies Socratic Questioning Cognitive therapy often has been equated with Socratic questioning. understand the underlying issues and concerns that are not at first apparent. and he doesn’t want to look bad. the partner might use this against the individual in the future. you interpreted that Mr. but it didn’t feel very good after all. If the individual does acknowledge that he or she was thinking in an extreme or distorted way. Therapist: Given that you interpreted his behavior that way. Is that right? Mrs. My husband has always been an excellent “student. which involves a series of questions to help an individual reevaluate the logic of his or her thinking. So it really doesn’t mean anything when he spends more time talking with me. and so forth. Often. If it is OK with you. concerned therapist with whom he or she can be open and honest in reevaluating cognitions. Socratic interventions may be more successful when the two partners are less hostile and hurtful toward each other. it sounds like Mr. Consequently. Z talked with you just because . Z: I know that sounds stupid. Therapist: Mrs. if a therapist begins to question one person’s thinking in the presence of a critical or hostile partner. Z’s behavior. frequently telling the individual that his or her thinking is distorted. Z spent more time talking with you in the evenings as you had wanted him to. such interventions can be effective but must be used cautiously. the client participates alone and works with a caring. the partner has explicitly blamed the individual for the relationship problems. the therapist helps Mrs. Z reevaluate her attribution for Mr. The context of individual therapy is quite different from that of couple therapy. When your partner does something or doesn’t do something. let’s spend a couple of minutes thinking through this a bit more. the individual’s partner is in the room. I was thinking that he’s only doing this because he knows we’re going back to therapy next week. I can certainly understand why it didn’t feel good and didn’t make the two of you feel closer as you had hoped it would. In couple therapy. however. When he was sitting there and talking to me. In the following dialogue. We have talked about the fact that it is not just what each of you does and doesn’t do that influences how you feel about the relationship. It’s not that he really wants to talk with me. Therefore.

can you tell Mrs. I don’t know if that was what was behind Mr. you didn’t feel very good toward him and certainly didn’t feel closer to him. Why don’t we do that? Mr. I suppose he may have suddenly decided that I am an interesting person after all. Z: I was being sarcastic. To make things better between the two of you. there really is a tendency to automatically interpret each other’s behavior in a negative way. but it is one possibility. Z. so it seems unlikely. that is another possibility.Brief Couple Therapy 213 he wanted to impress me and be a good student. and he does enjoy talking with me. Z’s behavior. Z’s behavior. Therapist: That is one possibility. Z why you spent more time talking with her this past week? Guided Discovery Guided discovery involves various interventions in which the therapist creates experiences for a couple so that one or both people may start to question their thinking and develop a different perspective on the partner and/or relationship. but it certainly sounds possible. Z spent extra time talking with you this week? I’m not assuming that these will be the actual reasons that he did talk with you. You will need to check yourself and see if you’re being fair to the other person and consider other interpretations. but I’m not sure if you are being sarcastic as you say it. For example. In addition. if a husband noticed his wife’s with- . Your interpretation certainly could be correct. If things go wrong in your relationship. As you said. Z: Well. Z’s behavior again. So let’s step back and look at Mr. Can you see that that is one possibility. Z. even if it is unlikely? Mrs. you didn’t even think about any other possibilities for Mr. he might be doing it because he knows it is important to me. However. Therefore. we also talked about the strong tendency you both have to interpret each other’s behavior in a negative way and that you often don’t give each other the benefit of the doubt. rather than just interpreting these on your own. what are some other possible reasons that Mr. but why would he suddenly see me as an interesting person after I’ve begged him to talk with me for years? It seems very unlikely. but what are some reasonable possibilities? Mrs. Therapist: OK. I think it will be important for you to step back and not make these automatic negative interpretations. Mrs. doesn’t it? I think the important thing to realize here is that your interpretation really is very subjective. It is possible. Therapist: Yes. often it is helpful to find out from the other person why he or she behaved that way. and he wants to make our relationship better. I guess even if he doesn’t find it particularly exciting to talk with me. What are some other possibilities for why he might have decided to talk with you more this past week? Mrs. but they certainly didn’t go through my mind this week. Z: I guess I can push myself to think of some others.

standards for relationships are addressed more appropriately with methods that focus on the advantages and disadvantages of living according to them. Thus. Her vulnerability. we provide a detailed discussion of addressing relationship standards as one example of cognitive restructuring with couples. First.g. the therapist could address this attribution in a variety of ways. her predictions might change. Instead. Discuss advantages and disadvantages of existing standards. the ways that the partners interact with each other (e.g. Clarify each person’s existing standards. rather than a lack of caring. If. we proceed through the following steps: 1. rather than directly challenging either person’s cognitions. It is difficult. These standards might involve an individual’s behavior (e. .g. whether it is acceptable to express disagreement openly with each other). they agree to start having conversations on a weekly basis and she sees that he is interested in her perspective when she expresses it. This new understanding might alter the man’s perspective without the therapist questioning his thinking directly. During the conversation. whether a partner should have close relationships with members of the opposite sex). For example. Some cognitions are not addressed best by evaluating their logic. because they are not based on logic. the therapist could structure an interaction in which the husband obtained additional information that might alter his attributions. often these involve values of what is right or wrong. how much time one should devote to an ailing parent).. as in the previous case example. Similarly. such as asking the husband to think of a variety of interpretations for his wife’s behavior and asking him to look for evidence either supporting or refuting each of those possible interpretations. In general. 2. the therapist might ask the couple to have a conversation in which the wife shared what she was thinking and feeling at the time when she withdrew. For example.. the therapist could use Socratic techniques. or how to interact with the environment (e. might have been the basis of her withdrawal. the man might find out that his partner withdrew because she was feeling hurt and cared about him a great deal. In contrast. if not impossible.. the therapist can help the couple arrange interactions that provide additional experiences or information that will challenge each individual’s cognitions. to debate the logic or truth of someone’s standards and values. standards involve beliefs about the ways that an individual or the couple should behave. however. a woman might develop an expectancy or prediction that her partner does not care about her opinion on a variety of issues. in guided discovery.214 The Art and Science of Brief Psychotherapies drawal and interpreted it as her not caring about him. in addressing relationship standards. In the rest of this subsection.

they should spend all of it together.Brief Couple Therapy 215 3. this polarization can be avoided or minimized. For example. First. each is asked to describe the pros and cons of conducting a relationship according to those standards. By encouraging each person to share both the positive and the negative consequences of his or her standard. What good might come from setting up your relationship with Mrs. Similarly. Mrs. In essence. Although I know it is not your own perspective. help revise them to form new acceptable standards. Thus. The wife would be invited to add to his perspective. However. A is that you each argue for your own position without trying to understand the other person’s perspective. As we discussed. couples often become polarized during this phase. A husband might conclude that given that the couple has little free time. we discuss how any given standard relevant to the couple usually has some positive and negative consequences. If a partner’s standards continue to differ. as well as potential negative consequences. with the husband adding his perspective. Let’s try to change that. A has told you her beliefs about what a relationship should be like relative to spending time together versus having time apart from each other. It sounds like what happens with you and Mrs. the couple might differ on their standards for how one should spend free time. A discussing the pros and cons of together time versus time alone follows: Therapist: Mr. Problem solve on how new standards will be taken into account behaviorally. the husband would be asked to describe the good things that would result from spending all or almost all of their time together. A in this way? . the wife might believe that partners should spend some free time together but that it is critical to have a significant amount of time away from one’s partner as well. with each person emphasizing the positive consequences of his or her perspective and the other partner noting the negative consequences of the person’s point of view. If standards need alteration. Once the partners are able to articulate their standards regarding time together and alone. I want you to push yourself to try to see what good things might come from you and Mrs. A brief excerpt of Mr. A spending some time together but also spending some of your free time separately. 5. Any way you do it is likely to have some pros and cons. there’s no right and wrong way for a couple to set up their relationship in this area. discuss the ability to accept differences. A. and Mrs. it is important to clarify each person’s standards in a given domain of the relationship. Without intervention. 4. the wife would be asked to list the pros and cons of spending some free time together and some free time apart.

thanks. in terms of concrete behaviors that each person would perform. Therapist: Mr. Thereby. I think you did that in a very sincere way. What additional good things do you think could come to the relationship from spending time apart from each other? After the couple fully discusses their different standards and the pros and cons of each approach. Other than when we’re at work. I guess it would mean that we both would have more separate experiences and could bring those back to the relationship and talk about them. Then. but we have so little free time that it is hard for me to think about spending some of it away from her. Also. it would certainly please her. trying to understand what it is like from Mrs. In particular. A might strive toward some agreed-on standard within which they spend a good deal of couple time together to feel close to each other. A. I would look forward to being back with her. so it would lead me to appreciate her. at times more explicit attention needs to be paid to addressing emotional factors in the relationship directly. and Mrs. Mr. After the couple agrees on a new standard. A has said. Much greater success occurs from slight alterations in standards that make them less extreme or more similar to the other person’s standards. In the previous example. they are asked to reach decisions about how this new standard would be implemented in their relationship on a daily basis. Mr. and that would be good. we are together almost all the time. I know that while we are apart. I know some good things could come from this. and Mrs. first let’s make sure that you’ve heard Mr. This is not an easy task. and it can require several sessions. A’s standard for couple versus individual time would be translated into specific concrete daily activities. they are asked to think of a moderated standard that would be responsive to both partners’ perspectives and that would be acceptable to each person. I want you to add to what Mr. But beyond that. A: Well. so rarely is an individual likely to give up his or her standards totally. therapists often work with couples in which one or both partners have either restricted or minimized emotions or . A correctly. A. Individuals typically cling strongly to their standards and values. Interventions Focused on Emotions Whereas many behavioral and cognitive interventions influence an individual’s emotional responses in a relationship. along with some time apart from each other to grow as individuals and have unique experiences to bring back to the relationship. So there isn’t much new for us to tell each other. A’s perspective and trying to see good things that could come from spending some time apart from each other.216 The Art and Science of Brief Psychotherapies Mr. Mrs.

Other individuals experience both positive and negative emotions. this can help both members of the couple understand that the person is experiencing a sense of loss. Sadness usually goes along with some experience of loss. or it might be the result of being raised in a family or culture in which certain emotions were rarely expressed. This can typify the person’s experiences in life in general or might be more focal to the current relationship. knowing the specific emotion that an individual is feeling often gives important clues as to how the person is experiencing the situation cognitively as well. a wife might know that she is quite angry but cannot relate this to what she is thinking or to experiences that occurred in an interaction with her husband. which then can be addressed. In addition. Addressing Restricted or Minimized Emotions Many partners in committed relationships seem to be uncomfortable with emotions in general or with specific emotions. Consequently. Similarly. emotions and cognitions are typically highly related. For example. and anger frequently is associated with an experience of injustice or unfairness. Some individuals experience and express minimal emotions in general or have problems accessing specific emotions. . They know that they feel good or bad but cannot articulate or differentiate the emotions that they are experiencing. Although emotions typically are related to thoughts and behaviors. so the ability to make such differentiations can be helpful to both the individual and his or her partner. Each of these broad domains includes more specific difficulties that individuals have with emotions and particular interventions that are appropriate for them. the partner of such an individual might complain that it is unrewarding to live with someone who has such restricted emotional responses. if an individual can clarify that he or she is feeling sad.Brief Couple Therapy 217 excessive emotional responses. some individuals have stronger emotional experiences but have difficulty differentiating among different emotions. some individuals have difficulty relating their emotions to their internal and external experiences. This can take a variety of forms. This difficulty can make both persons feel that they have little control over the relationship and are at the mercy of the individual’s emotions. Emotions carry a great deal of meaning. but their levels of emotional experience are so muted that they do not find their experiences within their relationships very gratifying. Thus. More generally. which appear to occur in an unpredictable manner rather than to be related to specific thoughts or behaviors. anxiety and fear usually are related to a sense of danger or unpredictability. To a degree. this might reflect an individual’s temperament.

and interpretations to draw out primary emotions. Johnson and Greenberg 1995) can be used to help individuals access and heighten emotional experience. the therapist promotes this safe environment by encouraging the partner to respond to the individual in a caring and supportive or. Consequently.218 The Art and Science of Brief Psychotherapies Finally. a variety of strategies drawn primarily from the emotionally focused therapy developed by Johnson and Greenberg (Johnson 1996. For example. First. In addition. encouraging the person to be aware of and express anger if he or she believes that this is wrong could result in negative consequences. the individual might attempt to avoid an emotion or escape once the session is focused on emotions. which help the individual feel less vulnerable. at least. if one partner believes that it is wrong to experience and express anger. Often. • Describe emotions through metaphors and images. include the following: • Convey that positive and negative emotional experiences are normal. In some instances. this must be done with appropriate . • Use questions. some individuals avoid what Greenberg and Safran (1987) referred to as primary emotions that are related to important needs and motives. Otherwise. the therapist tries to create a safe atmosphere by emphasizing that the experience and expression of both positive and negative emotions are normal. In addition. an individual might experience negative feelings such as anger and hostility. • Encourage acceptance of the individual’s experience by the partner. • Discourage attempts to distract self from experiencing emotion. reflections. the therapist might need to refocus the individual on an emotional experience and expression if he or she shifts the focus. these difficulties in experiencing and expressing emotions might warrant cognitive or behavioral interventions. Even so. the therapist might work with the individual to reevaluate his or her standards regarding the expression of anger. that person might suppress his or her own perception and expression of it and censure the partner for feeling and expressing anger. In this circumstance. • Clarify thoughts and then relate them to emotions. accepting manner when the person expresses various emotions. These interventions. These interventions are based on several broad principles. Therefore. rather than experiencing and expressing fear and anxiety to a partner. which we described in detail elsewhere (Epstein and Baucom 2002). individuals avoid the experience or expression of these emotions because they are seen as dangerous or vulnerable. Of course. Greenberg and Safran proposed that people cover these primary emotions with secondary emotions that seem less vulnerable.

The therapist’s goal is to help the individual enrich his or her emotional experience and expression in a manner that is helpful to both the individual and the couple. Just being touched is very frightening. but by then I already was upset. . B: Sure. A decision to focus on this category of interventions should not be based on a therapist’s belief that a “healthy” person should have a rich emotional life as well as a full range of emotional expression. B: That’s right. In this instance. He called his boss and stayed on the telephone for about 45 minutes. let’s go back to last night. B. Once a safe environment is created. It’s frustrating.g. encouraging the individual to use metaphors and images to express emotions. the therapist is attempting to help Mrs. if directly labeling emotions is difficult or frightening. it sounds like the interaction that you had with Mr. Is that right? Mrs. B reexperience her feelings from a negative interaction with Mr. which just makes it that much worse. it calls up all those horrible feelings of when you were abused as a teenager. he explained the emergency to me. One way to do that is to go back and look at that experience in more detail. and he made a call right away. Mr. Therapist: Fine. Therapist: Mrs. B doesn’t seem to understand what you were feeling. B.. “It sounds like when you and your husband start to become intimate sexually. and using questions. instead. I was so upset. the decision to use such interventions should be based on a careful assessment that a restriction in emotional experience and/or expression is interfering with this particular couple’s. reflections. but you’re having difficulty clarifying exactly what you were feeling. so I think it might be helpful if we could get more specific about what you were thinking and feeling. a variety of strategies can be used to heighten emotional experience. or the partner’s. You mentioned to him that he had a telephone message from his boss. so I just kept it to myself. B came in. although the experience might be quite painful on a temporary basis. As soon as he got off the telephone. and interpretations to draw out primary emotions (e. I felt like I didn’t have any reason to be upset.Brief Couple Therapy 219 timing and moderation to avoid overwhelming an individual with distressing emotions. Would that be OK? Mrs. but I couldn’t really understand it myself or explain it to my husband. In the following example. You mentioned that you were at home and had prepared dinner when Mr. the therapist attempts to heighten her emotional experience by having her recount the incident in detail. B last night was pretty upsetting for you. These interventions might include asking an individual to recount a particular incident in detail so that the emotional aspect of this experience may be evoked. is that right?”). well-being. I’m willing to do that.

We’re dependent on his job. Then I feel guilty and stupid for thinking that way. B: Well.g. one person can feel overwhelmed being around another individual who is so excited.. On the other hand. behavioral and cognitive interventions often can be of assistance. if an individual frequently is upset because he or she holds extreme standards that few partners could satisfy. B directly how you experience it emotionally when he seems to have so many things that take his time? Containing the Experience and Expression of Emotions At the other end of the continuum of emotionality. it makes me feel very low priority.220 The Art and Science of Brief Psychotherapies Therapist: So you were upset by the time he got off the telephone. Therapist: Good. upbeat. B: I guess it’s sadness. clinicians more often confront couples in which one person has difficulty regulating the experience and expression of negative emotions. a real sense of sadness and defeat. Typically. strong arguments. if an individual frequently is upset and angry because of a partner’s displeasing behavior. Therapist: And when you think that you are unimportant and a low priority to Mr. At times. A variety of strategies can help couples in such circumstances. What was more upsetting was that he always seems to have something else to do that is more important than I am or our relationship is. In addition. this is of concern to the couple if one or both partners are experiencing and expressing high levels of negative emotion or are expressing these emotions in settings that are not appropriate. which was getting cold. B. At the same time. However. I think you’re starting to figure it out. then the therapist might focus on behavioral interventions to alter the partner’s unacceptable behavior. I was disappointed because I had prepared a nice meal. I was thinking several different things. which result from extreme negative emotions. In addition. the therapy sessions can be very difficult to control because of frequent emotional outbursts as a couple confronts problematic aspects of their relationship. and I know it is not a 9-to-5 job. partner abuse). First. a therapist may work with partners who have difficulty regulating their experience and expression of emotion. and happy on an ongoing basis. Still. For example. Why don’t you tell Mr. As noted earlier. so he has to respond. one person’s extreme exuberance and frequent expression of strong positive emotion can become problematic. or extreme behaviors (e. some interventions are more focal to addressing extreme emotional experiences: . then focusing on modifying those standards is appropriate. The therapist may find such couples quite demanding because their lives appear to revolve around a series of emotional crises. in some couples. What were you thinking about while he was on the telephone? Mrs. what emotions do you experience? What are the feelings that go along with feeling unimportant and a low priority? Mrs.

Linehan (1993) developed a variety of interventions to assist individuals with poor affect regulation. expressing strong anger when one person is leaving the house to go to work. frequently resulting in strong expressions of emotion to the partner. We explain placing limits on this intrusion to couples as a form of healthy compartmentalization. One of these interventions involves teaching individuals to tolerate distressing emotions. Tolerate distressing feelings.Brief Couple Therapy 221 • • • • Schedule times to discuss emotions and related thoughts with the partner. or initiating a conversation with strong negative emotion once the couple has turned off the lights to go to sleep. The goal of this intervention is to restrict or contain the frequency with which and settings in which strong emotions are expressed. Similarly. likely will result in further upset for both people. One useful strategy is for the couple to schedule times to discuss issues that are upsetting to one or both partners. Within the context of working with parasuicidal individuals and persons with borderline personality disorder. For example. it can be helpful to coach the individual in focusing on the current moment. In particular.” Seek alternative means to communicate feelings and elicit support. Practice “healthy compartmentalization. Some individuals seem to assume that if they are upset. and it is influenced by . then an individual with poor affect regulation is more likely to express strong feelings whenever they arise. If couples have not set aside times to address issues. This intervention can be helpful in making certain that problems and expression of strong negative affect do not intrude into all aspects of the couple’s life. this can be helpful in ensuring that strong negative emotional expression does not occur at times that are likely to lead to increasing frustration for one or both persons. Although her interventions do not focus on addressing strong emotions in an interpersonal context. if one partner is upset about a given aspect of the relationship. often they are applicable. it is important for that partner to restrict that sense of upset to that one issue and to allow himself or herself to enjoy other positive and pleasurable aspects of the relationship when they occur. they need to do something immediately to reduce their uncomfortable emotional experience. Many individuals with poor affect regulation allow their upset in one domain of life to intrude or infiltrate many other aspects of their lives. That is. Some people find that they can resist expressing strong negative feelings if they know that a time has been set aside to address concerns. Poor affect regulation exists on a continuum. Helping individuals become comfortable with and accepting of being upset with their partners or their relationship without needing to address every concern immediately can be helpful.

In considering each of these domains. the therapy may focus on how the couple can adapt most effectively to an extraordinary number of external environmental stressors that they are confronting.222 The Art and Science of Brief Psychotherapies several factors. and illnesses of aging parents. or using other alternatives for releasing tension and strong emotion can be productive for the individual. keeping a journal or diary to express emotions. Integrating Behavioral. including normal individual differences between the two partners. such as a collection of parenting problems. the therapist working collaboratively with the couple identifies the most salient factors to address in couple therapy. when individuals have extreme difficulty in regulating their experience and expression of negative emotions. Attempting to address all of these factors in a brief therapy format is impossible and would likely be overwhelming to both the therapist and the couple. such as dialectical behavior therapy. for a given couple. Although the previous strategies can be of use to many couples. rarely are all of these factors of central importance to a given couple. we have noted a variety of factors that can contribute to relationship functioning. In the current chapter. Finally. and emotional interventions are available to the therapist. perhaps from individuals other than their partners. and the way that the couple relates to their social and physical environment. Thus. behavioral. it is easier for the therapist to address upsetting aspects of the relationship in a couple therapy context. psychopathology in one or both individuals. couple therapy alone often is inadequate. financial difficulties. Furthermore. it is imperative that a therapist focus on the most central issues of relevance to a couple. As the individual becomes more effective in regulating negative affect. Other couples may differ in the degree of closeness that they need in order to be satisfied. we typically refer the individual for some form of individual psychotherapy. relying on other friends for expressing some concerns. Cognitive. which assists the person in developing skills to regulate affect. and Emotional Interventions In working with couples within a brief format. This approach is not intended as an alternative to addressing an individual’s concerns with a partner but as a means of moderating the frequency and intensity with which the person’s emotions are expressed to the partner. In such instances. Thus. couple interactive processes. it can be helpful for partners to seek alternative ways to communicate feelings and elicit support. cognitive. Instead. Yet other couples might lack the ability to . including the quality of the couple’s relationship.

they could wait until she returned. and we have good friends and family. but there had been little for her individually. C to stay home and raise the children. they both wanted Mrs. Identifying these most central factors and focusing on them can allow a couple therapist to work in a brief format and make substantial progress with many couples. we have enough money. C Mr.” Mr. She almost never did anything for herself and was resentful. We really need your help. the therapist concluded that they were experiencing difficulty because they had allowed . C and the children where she was going or when she would be back. they sought couple therapy primarily because Mrs. and she felt stifled. they both began jobs but had decided that Mr. She loved Mr. we’re all healthy. As he stated it. She felt caught in a helpless situation. C felt totally confused coming into therapy. a couple in their mid 40s. As she explained it. and now it’s time for me. and Mrs. If they wanted dinner. but it’s like she got a brain transplant. C had married directly after undergraduate school and were excited to begin their life together. either I as an individual can survive. She had started going out to dinner and movies with some of her female friends. or whatever with her friends at night in the middle of the week without telling us or explaining what is happening. Now she talks about dying if she stays in our marriage. It looks like my wife. I don’t understand what is happening.” After conducting an assessment with the couple. C. C and their two children but felt that if she stayed in this marriage any longer. They had grown up in what they experienced as wonderful families. The kids are confused and feel as if they have lost their mother. I’ve given my whole adult life to our marriage. she wants to change it. I thought everything was fine. In the following example.Brief Couple Therapy 223 express emotions and therefore experience a disengaged relationship. We have two wonderful children. or our relationship can survive. and suddenly. “I feel like I’m living with a stranger. movies. They had dated through most of college and described their early relationship as wonderful. C’s career would be the primary one in their relationship. I don’t know what to do. there was no room for her in their relationship. the therapist focuses on the most central factors in working with Mr. Summary Case Illustration: Mr. refusing to tell Mr. C had distanced herself from Mr. and Mrs. she would “die” emotionally. or they were free to prepare it themselves. She had been the good mother and the good wife. and an important part of that was being with their mothers when they were young. C was unhappy with their relationship and feeling somewhat depressed. After 24 years of marriage. Mrs. “Right now. as if she had stopped growing 20 years ago. C. After they graduated. their sexual and affectionate life had come to a halt. and Mrs. They both wanted children. It feels like we’ve been on one life course. She’s going out to dinner. and once their children were born. and as she expressed it.

and they did not want to lose it. and she spent little time doing things for herself. Mr. C and the children could accommodate her individual needs. the children made it to their various appointments and sporting events on time. this couple had allowed their relationship to dominate Mrs. In doing so. in which Mrs. these benefits to the family came at quite a price to Mrs. such as taking additional classes. because he had had no awareness of them. Both Mr. because the couple had not learned how to integrate a focus on both her individual and their family well-being. and couple well-being. exercising. he came to realize that listening to these feelings would have the greatest likelihood of creating a relationship that was fulfilling to Mrs. and Mr. the couple spent time talking about what each of them needed as individuals within the marriage to feel fulfilled. From the family’s perspective. C’s concerns. C found it frightening to hear of Mrs. C found it liberating to see that her husband listened and wanted to understand her. First. the therapist focused on the balance between individual and couple well-being. and Mrs. or socializing with friends. and dreams were . C were both eager to try. and now she was distressed and felt desperate. C’s individual well-being. As she began to express her concerns. neither partner really knew how the other felt. their school projects were always among the best in their class. disappointments. Although it was unintended. However. the arrangement worked quite well. family. Mrs. All couples need to balance individual. In developing a treatment plan with this couple. and Mrs. Although Mrs. The therapist encouraged them to discuss this at two levels: what they needed day to day and what their long-term goals.224 The Art and Science of Brief Psychotherapies their relationship to become skewed in the following way. she undertook in a great deal of self-sacrifice for the well-being of the family overall. Things functioned smoothly at home. She was swinging from one extreme approach to another. After spending considerable time in therapy discussing these concerns and recognizing that they were now in a new developmental stage in their relationship. and experience of being stifled. C. First. the therapist focused on helping the couple share their thoughts and feelings about the situation that they were confronting. C did not have to attend to young children’s needs. C personally. and Mrs. plans. but with reassurance from the therapist. He was quite worried that she might leave their marriage. Mrs. C’s career flourished. Mr. A central issue of the treatment became whether Mrs. when they entered therapy. In mutual collusion with her husband and with her own full consent. C had learned to keep her feelings to herself and to focus on the family’s well-being. The couple next spent a considerable amount of time problem solving and decision making regarding these issues. She let her personal relationships outside of the family slip. Mr. Mrs. C had changed from being a woman with a fulfilling career to being exclusively a wife and mother. C was somewhat skeptical that Mr. These conversations had several different but related foci. C could experience personal growth within the context of her family. C focused their energy on how to rebalance the relative emphases between individual and couple growth and well-being. C greatly valued what they had built together during their marriage.

she needed to distance herself somewhat from Mr. he was able to express to Mrs. and their therapist discussed ways that the couple could maintain their sense of closeness and intimacy while helping Mrs. who was supportive of him and pointed out that she willingly had helped to develop their relationship in its current form.Brief Couple Therapy 225 as individuals. and explored ways to rejuvenate their sexual relationship. C heard these various requests from Mrs. In part. Consequently. he was open to incorporating them into their lives. Mr. they regularly scheduled times to go out together as a couple. She was able to explain to him how she had to create some more distance in order to focus on herself because she had such a tendency to give up her own needs for the family. They had simply inadvertently gone too far. C develop a healthy sense of autonomy within their relationship. C. they had allowed their family life to drift into a skewed form that ignored Mrs. the therapy was very effective. during therapy sessions. continued to have couple conversations during the week. Consequently. and behavioral interventions to help the couple address some balance between individual well-being and couple functioning. He shared these feelings with Mrs. As Mr. the therapist asked the couple to address their standards for the importance of individual well-being relative to couple and family functioning. given that they had built their family life in a different way. When the couple discussed Mr. and he found this difficult to experience. As Mr. She decided to join a health spa and exercise regularly for the first time in 20 years. C to place an emphasis on her own growth and well-being. As the couple worked through these issues in therapy. C. C. She also wanted to reestablish some of her female friendships that had lapsed. From a long-term perspective. adaptive reasons. He wanted her to be fulfilled individually but simply had not known what she needed. She needed a sense of contributing as an individual to her community. C came to recognize this. C wanted to do substantial volunteer work with the animal protection society. C’s individual needs. Mrs. As they discussed these issues. C was able to clarify both for herself and for Mr. C. C’s needs on a daily basis and his longterm goals. C how he sometimes felt rejected and devalued. C that she needed time during the week for herself as an individual. he felt somewhat guilty that their relationship had become so skewed. For Mrs. emotional. although this was difficult to do because she had neglected them over the years. Mrs. C. He acknowledged that it would be difficult. The therapist used a variety of cognitive. In discussing these issues. Over a period of approximately 6 months. They agreed that they had developed their relationship over the years in a way that accommodated his immediate and long-term needs. She also decided that she wanted to become involved in projects at her local church without Mr. Mrs. C. They both agreed with the therapist that some balance was necessary. the couple was successful because both partners were relatively well-adjusted individuals who were . but he was committed to making these changes. They decided that together they would talk to the children and explain to them some of the changes that they were trying to make in the family for healthy. and without focusing on it. he wanted to change very little for himself personally.

Guilford. Brunner/Mazel. Conclusion Had there been more long-term anger. Ingram RE. Edited by Jacobson NS. at the beginning of couple therapy. or insecurity in one or both partners in this case illustration. Often. resentment.226 The Art and Science of Brief Psychotherapies committed to their relationship and cared a great deal about each other. Shoham V. 1995. 2000. New York. Mueser KT. Kuschel A: Are waiting list control groups needed in future marital therapy outcome research? Behavior Therapy 34:179–188. New York. with treatment plans being adapted as the therapy proceeds. Epstein N. or the results likely would have been compromised. Rush AJ. they were able to make changes in a rather rapid fashion. Guilford. C’s individual wellbeing. Epstein N: Cognitive-Behavioral Marital Therapy. it is impossible to predict whether a particular couple can make changes in a brief period. New York. et al: Cognitive Therapy of Depression. 1979 . Shaw BF. Consequently. References Baucom DH. in Clinical Handbook of Couple Therapy. Rankin LA: Cognitive aspects of cognitive-behavioral marital therapy. Epstein N. 2003 Beck AT. disengagement. once they saw the basis for their difficulties. in Handbook of Psychological Change: Psychotherapy Processes and Practices for the 21st Century. Brief couple therapy is a viable treatment modality when interventions are used that focus on central issues of importance to the couple and when the couple engages in therapeutic strategies in their day-to-day lives outside of the session. Consequently. Gordon KC: Marital therapy: theory. et al: Empirically supported couple and family interventions for marital distress and adult mental health problems. pp 280–308 Baucom DH. but the empirical literature is clear in indicating that it is efficacious for many. the therapist should attempt to design interventions in a way that allows and promotes rapid change for a couple. although it was difficult to shift their family patterns that de-emphasized Mrs. 1998 Baucom DH. New York. 1990 Baucom DH. Wiley. Edited by Snyder CR. Brief couple therapy is not successful with all couples. practice. and empirical status. pp 65–90 Baucom DH. Gurman AS. Hahlweg K. J Consult Clin Psychol 66:53–88. the treatment likely would have taken longer.

in Clinical Handbook of Couple Therapy. J Consult Clin Psychol (in press) Epstein N. Babcock JC: Integrative behavioral couple therapy. Atkins D. Behrens BC: A comparison of the generalization of behavioral marital therapy and enhanced behavioral marital therapy. CA. some data evaluating it. Vol 6. pp 121–141 Linehan MM: Cognitive-Behavioral Treatment of Borderline Personality Disorder. and the Process of Change. Sanders MR. Sanders MR. Baucom DH: Enhanced Cognitive-Behavioral Therapy for Couples: A Contextual Approach. Concepts. New York. 1995. 1989 Stuart RB: Helping Couples Change: A Social Learning Approach to Marital Therapy. New York. Jacobson NS. 1990 Jacobson NS. Safran JD: Emotion in Psychotherapy: Affect. 1987 Halford WK. Behrens BC: Self-regulation in behavioral couples’ therapy. New York. Washington. Mash EJ. Brunner/Mazel. Gurman AS. Guilford. Costanzo M. New York. pp 309–342 . Edited by Jacobson NS. in Gender Issues in Contemporary Society: Claremont Symposium on Applied Social Psychology. Edited by Jacobson NS. 1993 Halford WK. 1979 Johnson SM: The Practice of Emotionally Focused Marital Therapy. New York. 1996 Johnson SM. Research Press. Gurman AS.Brief Couple Therapy 227 Christensen A. pp 31–64 Christensen A. 2002 Greenberg LS. 1994 Iverson A. J Consult Clin Psychol 57:39–46. pp 113–141 Christensen A. Baucom DH: Behavioral marital therapy outcomes: alternate interpretations of the data. in Behavior Change: Methodology. 1993. 1973. Sage. Champaign. DC. Guilford. Edited by Oskamp S. New York. Berns S. Hops H. New York. Guilford. Handy LC. IL. Newbury Park. Cognition. J Consult Clin Psychol 61:51–60. Margolin G: Marital Therapy: Strategies Based on Social Learning and Behavior Exchange Principles. Behav Ther 25:431–452. Wills RM: Behavioral versus insight-oriented marital therapy: effects on individual and interspousal functioning. Guilford. Behav Ther 21:129–138. in Clinical Handbook of Couple Therapy. American Psychological Association. Greenberg LS: The emotionally focused approach to problems in adult attachment. 1980 Weiss RL. and Practice. 1993 Snyder DK. Brunner/Mazel. Edited by Hamerlynck LA. Patterson GR: A framework for conceptualizing marital conflict: a technology for altering it. Guilford. Heavey CL: Gender differences in marital conflict: the demand/ withdraw interaction pattern. 1995. et al: Traditional versus integrative behavioral couple therapy for significantly and stably distressed married couples.

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Part II Special Topics .

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8 Essential Ingredients for Successful Psychotherapy Effect of Common Factors Roger P. I had a psychiatric resident in psychotherapy supervision who dutifully brought audiotapes to each of our supervisory meetings. It is true that psychotherapy sessions 231 S . say hello.D. Ph. “Don’t you ever greet your patient. Each psychotherapy session we reviewed began with minutes of painful silence and a patient made clearly uncomfortable by the soundless process. everal years ago. “You never told me to!” This vignette presents an extreme example of a novice psychotherapist trying to slavishly adhere to a preconceived notion of how to do psychotherapy while ignoring some of the basic rules of interpersonal sensitivity and human interaction. after observing the pattern for several weeks. Finally. Greenberg. I asked the resident. or ask patients how they are doing?” The resident replied.

Not surprisingly.232 The Art and Science of Brief Psychotherapies have goals and purposes different from those typical of friendships. security. 1975. positive results appear to stem more from a variety of factors common to many forms of treatment than from the application of specific techniques unique to one approach to psychotherapy. senior clinicians espousing different orientations were more similar in their conceptions of ideal therapy relationships than were experienced and novice therapists claiming allegiance to the same theoretical approach! . it is important to remember that psychotherapy is enhanced within any particular system when the therapist has good commonsense judgment and hardy interpersonal skills. even when therapists feel that they are applying diverse forms of psychotherapy. evidence also indicates that it is possible to go too far in trying to adhere to a manual. The verdict of the dodo bird in Alice’s Adventures in Wonderland (Carroll 1865/1962)—“Everybody has won. 1950b). flexibility. Faithfulness to a manual’s directives may come at the expense of factors known to have a positive effect on outcome. and all must have prizes”—has been used as the subtitle for some classic publications on psychotherapy (Luborsky et al. and the building of a therapeutic alliance. The commonalities are of paramount importance. Reviews of the psychotherapy empirical outcome literature consistently show that psychotherapeutic treatment produces benefits but also that it is difficult to detect clear differences in the comparative worth of different brands of psychotherapy. Seasoned therapists appear to learn this and naturally drift toward similar behaviors as they hone their psychotherapy skills. Over the years. such as therapist acceptance. For example. Therefore. the idea that successful psychotherapies have certain things in common has continued to receive research support. research has clearly supported the idea that there is more to effective psychotherapy than simply picking out a specific psychotherapy model and following the techniques in a robotic manner. as well as be influenced by the interaction. and respect for the pain of another human being. Yet the ability to help someone open up to threatening thoughts and feelings. As the quotation suggests. In fact. some well-known studies published more than 50 years ago indicated that there was considerable agreement in descriptions of the ideal therapeutic relationship provided by experienced therapists of varying theoretical persuasions (Fiedler 1950a. is rooted in a process that establishes a certain amount of safety. In fact. although some research has suggested that it may be useful to learn to do psychotherapy from treatment manuals (which provide a blueprint for applying specific techniques). Rosenzweig 1936). warmth.

It may also mean encouraging the patient to recognize his or her personal assets and the interpersonal support that may be available to him or her. Three other factors were judged to be more important. account for only about 15% of the improvements that are achieved (Asay and Lambert 1999. when needed. patients learn to repeat those actions that result in beneficial outcomes and to avoid those that turn out to be selfdefeating. degree of psychological-mindedness. and capacity to point to a central problem. in successful therapies. a review of the literature led to the conclusion that about 40% of the improvement resulting from psychotherapy can be attributed to these factors. motivation. it involves teaching patients that change evolves from their own efforts. Perhaps most critically. notable appraisals of the psychotherapy literature concluded that techniques. patients are led to see that things they are doing create either a positive or a negative influence on how situations are likely to turn out. However. which are associated with particular models of psychotherapy. severity and number of symptoms. Most prominently mentioned are the patient’s ability to relate. 2) relationship factors.Essential Ingredients for Successful Psychotherapy 233 Common Factors Attempts to specify those components most needed for successful treatment generally regard techniques unique to particular types of psychotherapy as being less important than some overriding common factors. such as the level of job stability and the amount of social support or community resources available. For instance. These other determinants of outcome are 1) patient variables and extratherapeutic events. Lambert 1992). Attention to patient factors includes. Patient Variables Some may find it surprising that patient/client variables and the circumstances in an individual’s life are considered to play such an important role in outcome. By becoming aware of the effect of their own behaviors. All too often. educating clients about the role and responsibilities of the psychotherapy patient. and 3) placebo/hope/expectancy effects. Another salient point that follows from an appreciation of patient variables is related to trying to create balance between confrontation and support within psychotherapy sessions. This typically requires helping the patient to view psychotherapy as a collaborative effort in which he or she will play an active and important part. They also learn that some of the assumptions and expectations they hold about other people’s thoughts and judgments are inaccurate. Over time. psychotherapy . such as systematic desensitization or transference interpretations. Also important are life circumstances.

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seems to deteriorate into a single-minded exploration of what is going wrong in a patient’s life and where his or her particular deficiencies may lie. This can be demoralizing and reinforce already exaggerated negative self-perceptions. It is wise to keep in mind that over time, patients also need to be channeled toward looking at areas of strength and personal assets they may be overlooking. In fact, therapists should routinely mentally catalogue such positive information during the early sessions of treatment so that a balanced picture can be discussed later, when the patient might be more ready to consider it. Obviously, timing is critical in psychotherapy. The success of interventions is likely to be determined by a blend of therapist experience and artfulness in helping the patient to allow personal material to emerge. Surprisingly, even positive information about a patient can prove threatening if it conflicts with the negative self-portrait the patient has assembled from past experiences with significant figures (such as parents). A therapist may quickly lose credibility and alienate a patient by being too supportive and reassuring. Conflicts between accepting positive information and loyalty to critical parental pronouncements are common and must be handled with sensitivity and patience. This concern is of particular importance in brief psychotherapy because therapists may unwittingly estrange patients in their zeal to intervene swiftly with reassurance and support. Novice therapists frequently fail to recognize that all patients do not enter treatment with equal commitments to making changes in themselves. Patients are often pressured into treatment by spouses, parents, employers, and even the courts. Therefore, for many patients, attempts to promote active techniques for altering behaviors and emotions can result in resistance and even dropping out of treatment. It is useful to remember that there are stages of change and that therapists need to match their techniques to a patient’s degree of readiness to engage in the behavior change process. In the Stages of Change Model as presented by James Prochaska and colleagues (1992, 1995), stages of change unfold over time and involve progression through six levels of patient readiness and involvement: 1) precontemplation, 2) contemplation, 3) preparation, 4) action, 5) maintenance, and 6) termination. Although I do not review the various stages in detail here, it is important to note that most patients do not present for treatment ready to engage in actions to ameliorate their problems. In fact, the Prochaska group estimated that only about 10%–15% of people are prepared to take action when they enter psychotherapy. Consequently, it becomes the task of the therapist to help patients move from a lack of awareness of their problems (precontemplation), to acceptance of the idea that they have

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problems (contemplation), to consideration of making changes (preparation), to active attempts to do something to improve the situation (action), and finally to anticipation of future stressors (maintenance). The therapist initially may need to play the role of nurturing parent while helping the patient to examine the reasons for resistance to change and anticipating how he or she might attempt to sabotage the treatment in the future. As patients begin to contemplate making changes, therapists might most appropriately assume the role of the Socratic teacher who facilitates expanded patient self-awareness and insight. When patients start to plan for action, the therapist may take on the role of experienced coach, who, in concert with the patient, helps to develop a game plan for change. During the action phase of brief treatments, psychotherapists behave more as vigorous-change agents and consultants, offering support and advice while patients struggle with the ups and downs of trying to make progress by engaging in new behaviors. Of course, patients’ movement through these phases does not proceed uniformly in a straight line, and therapists must learn to regulate their activities to match the patient’s level of readiness.

Relationship Factors
Probably the common factor most studied in the research literature is the therapy relationship and the role it plays in determining treatment outcome. Investigators have repeatedly affirmed the importance of a good therapeutic relationship. Even early in treatment, the nature of the relationship—the bond formed between therapist and patient—exerts a powerful influence on how the encounter is likely to turn out. It has been estimated that at least 30% of patient improvement can be attributed to relationship factors (Lambert 1992). Determining which elements in the relationship are of most importance has been the subject of much speculation and study. Although Freud emphasized the patient’s tendency to misread current relationships as reduplications of significant malignant past relationships, he also was aware of the need for patients to identify the therapist with kind, tolerant figures with whom they could develop an interpersonal attachment. This bond of attachment has been labeled the therapeutic alliance and is presumed to give the therapist the leverage needed to help the patient face frightening and unacceptable thoughts and emotions. Central to the development of an alliance is the establishment of a collaborative atmosphere in which mutual agreement exists on the goals and tasks of therapy, as well as mutual trust and acceptance. Evidence suggests that the therapist may facilitate this type of atmosphere by showing high levels of

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empathic understanding, warmth, and unconditional positive regard (factors emphasized in the influential writings of Carl Rogers [1957]). Interestingly, setting up a strong therapeutic alliance seems to be as important for a positive result with psychiatric medications as it is with talk therapy (Greenberg 1999). For example, a positive treatment outcome with antidepressants was found to be more likely when the prescribing clinician was perceived as empathic, caring, open, and sincere. Other relationship-related findings indicate that treatment gains may stem less from the development of patient insights (as psychoanalysts might expect) than from patients having a “corrective emotional experience.” This protherapeutic factor refers to patients perceiving their therapists as treating them in a more constructive and supportive manner than did the significant authority figures in the patient’s past. The contrast with the past offered by this more positive relationship might help patients to feel more secure and confident about trying new solutions to old problems. Several other change-inducing ingredients are common to most forms of psychotherapy. These include catharsis (in which patients release emotional tensions by unburdening themselves of troubling problems), identification (as patients learn to imitate a therapist model), and the development of feelings of mastery (as patients learn some type of framework for making their problems understandable and thereby gain a sense of control). Incidentally, psychodynamic approaches to therapy sometimes have advocated that unique benefits may arise from focusing interpretations on the relationship between clinician and patient. These transference interpretations are designed to show patients that impulses and feelings for the therapist often result from past emotions and thoughts concerning significant others that are then projected (or transferred) onto the therapist. Although the transference concept has proven useful, transference interpretations have a possible downside. Research not only challenges the idea that heavy use of such interpretations is helpful but also actually suggests that use of such interpretations may be harmful, particularly with patients who are interpersonally adept (see review by Fisher and Greenberg 1996). Increased reliance on transference interpretations has been associated with more negative treatment outcomes and more negative effects on the therapist–patient relationship. Such interventions may lead patients to feel criticized and to withdraw. Overly stressing that patients need to examine their relationship with the therapist during psychotherapy sessions tends to lead to perceptions of the therapist as less supportive, less approving, less engaged, and more impatient. All of these qualities operate against the treatment being seen as helpful. In general,

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if the relationship is to be discussed, the discussion needs to be well timed, handled with great care, and not too frequent. These findings support the brief therapist’s stance of downplaying interactions about the transference and emphasizing instead a positive treatment relationship and a well-defined therapeutic focus. Another relationship-related tip concerning how not to conduct psychotherapy involves the concept of pathogenesis, which was described in the empirical literature more than 30 years ago. Pathogenesis refers to the degree to which therapists (knowingly or without awareness) use others who are dependent on them to satisfy their own needs, no matter what the cost to the dependent individual. A series of studies with very disturbed patients indicated a strong relationship between the level of therapist pathogenesis and negative treatment outcome. This observation seemed particularly striking with novice therapists. It was speculated that as experience increased, therapists either learned to control this aspect of their personalities or actually decreased their levels of pathogenesis. These findings are consistent with other indications that therapists who do not radiate relationship-enhancing characteristics actually might be harmful to those with whom they work. Such practitioners have been labeled psychonoxious.

Placebo/Hope/Expectancy Effects
The strength of placebo and expectancy effects in psychotherapy (as well as in all of medicine) has been widely acknowledged. These effects are estimated to be at least as powerful as those attributed to specific techniques and account for a significant portion of the improvement experienced by patients. It is important to realize that even though the term placebo is routinely associated with treatments that have no known specific active ingredients, providing a “treatment experience” for patients, no matter what form it might take, is not equivalent to doing nothing. In fact, researchers often have been startled by the improvements observed following a course of treatment presumed to be inert. The mere fact of meeting with a sanctioned caregiver appears to be generally helpful, independent of the specific type of treatment that is being delivered. Although these effects are sometimes demeaned by comments about results being due to only nonspecific psychological factors, their consistency and magnitude cannot be ignored. What might account for the ubiquitous power of caregiving encounters? Some important ideas on this topic appear in the classic writings of Jerome Frank (1973; Frank and Frank 1991). Frank proposed that many individuals enter therapy feeling powerless to change and shaken. They lack confidence in their ability to cope and

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feel that they will be personally unable to solve problems facing them. He theorized that four factors are inherent in all psychotherapy approaches that help to diffuse these feelings of demoralization and assist the patient in becoming mobilized: 1. Having an emotionally charged relationship through which the therapist can instill hope that change can occur 2. Having a therapeutic setting that reinforces the expectation that others have been helped to change by this particular therapist 3. Having a therapeutic rationale (or “myth”) that provides a plausible explanation for problems, compatible with the patient’s belief system 4. Having a particular set of procedures or rituals that enhance belief through perception of the therapist as a master of the method Having these hope-inspiring factors in place increases the likelihood that a patient will engage in the treatment and feel motivated to make changes.

Psychotherapy Integration
There is general consensus among experienced therapists that it is useful to master one or more major approaches to psychotherapy (such as those outlined in this book), but there has also been a growing movement aimed at integrating various approaches to treatment. The desire for integration is fueled by recognition that many approaches have resulted in patient benefits, with no one type of therapy having consistently bested the rest for all patients and most types of problems. Therefore, in the face of expanding numbers of therapy models and acknowledgment that commonalties play a significant role in producing treatment gains, the field has begun to open to the idea of amalgamating theories and techniques from different schools. The idea is to determine which combinations can be expected to produce the best outcomes for which types of problems. The resulting flexibility in case conceptualization and technique application offers a better fit with research evidence than does unwavering allegiance to single-therapy systems. In line with this position is the finding by several surveys that practitioners most often choose the terms integrationist or eclectic when asked to identify their preferred brand of psychotherapy. Of course, to be skillful as an integrationist, one must develop expertise with several forms of psychotherapy. It is our hope that this book will provide guidance in learning basic strategies associated with several widely accepted forms of psychotherapy.

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One obstacle blocking the path to integration is the notion that therapy systems need to compete with one another for superiority. This need not be so. It is perhaps more useful to view diversity as a strength, with different orientations complementing one another. A knowledgeable clinician might then be able to approach problems with a much greater range of therapeutic tools and ways to conceptualize troubling symptom puzzles. In this regard, complementarity often has been suggested as a way to synthesize the strengths of psychodynamic and behavior therapies. For example, Paul Wachtel (1977, 1987) suggested that people are helped when their insights are used to help guide them toward action. Therefore, a psychodynamic approach could be useful in revealing to patients how and why they are unnecessarily defending themselves from certain thoughts, feelings, and behaviors. These insights might then permit the application of behavioral techniques aimed at changing behaviors and altering distorted self-perceptions. Similarly, some have suggested that behavioral techniques might be used at the start of some therapies to provide a degree of initial symptom relief and open the door to patient exploration of some of the dynamic reasons for the turmoil they are experiencing. The Stages of Change Model (described earlier; Prochaska et al. 1992, 1995) provides another example of how different theories of therapy might be used in a complementary way. For those at the precontemplation stage, unaware or underaware of their problems, a psychodynamic approach may offer some special initial benefits. This is because the approach provides skillful suggestions for how therapists can help patients overcome resistances and increase awareness of the sources of discomfort. When a patient reaches the stage of contemplation, in which he or she has awareness of a problem but no commitment to action, cognitive therapy techniques may prove helpful in focusing the patient on how he or she can move ahead. Once the patient is ready for action, behavioral strategies may be used to particular advantage. By appropriately matching each model to the patient’s level of readiness for change, the combination might afford the possibility of moving the patient along to a higher level of benefit than would be attained from any one approach used in isolation.

Conclusion
The purpose of this book is to present a primer on how to conduct treatment with several well-known psychotherapy models. As such, various treatment techniques and rationales are described for the reader. The aim

Lambert MJ: The empirical case for the common factors in therapy: qualitative findings. DC. or it has the power to make patients worse off than they would have been without any treatment at all. American Psychological Association. the literature offers encouragement through the identification of all the gains that can accrue simply from meeting with a caregiver who presents a reasoned approach to problems. pp 33–56 Carroll L: Alice’s Adventures in Wonderland (1865). England. Hammondsworth. in The Heart and Soul of Change: What Works in Therapy. as outlined earlier in this chapter. Middlesex. In contrast. These factors appear to be necessary ingredients for good outcome. Clearly. Much of the treatment potency for harm (as well as for good) rests in the qualities that the therapist brings to sessions. Washington. is easy to talk with. 1999. 1962 . and is optimistic that the therapy will be helpful. One of the unexpected findings uncovered by research is that psychotherapy can be for better or for worse. and placebo/hope/expectancy effects. As specific techniques are matched with the patient’s problems and readiness for change. In emphasizing common factors. is nonempathic. that patients be able to attribute gains made to their own efforts. deterioration is most likely when the therapist’s needs supersede those of the patient and too much emphasis is placed on analyzing the nature of the treatment relationship. Of special note is the indication that one ultimate goal of effective psychotherapy is to give the patient the confidence and the framework to play an active part in his or her own improvement. the relationship. and is judgmental. Edited by Hubble MA. no one approach to therapy has cornered the market on effective ingredients. Miller SD. Investigations indicate that negative outcomes are more likely when the therapist does not listen well. Evidence suggests that treatment results are maximized when the therapist can establish an atmosphere of collaboration and trust and an expectation of future wellbeing. keeping common factors in mind should go a long way toward helping any therapist to optimize treatment effects. if benefits are to last. It is important.240 The Art and Science of Brief Psychotherapies of this chapter has been to briefly outline those factors that cut across virtually all treatment approaches and account for most of the effects obtained with any type of psychotherapy. I have highlighted the role played by patient variables. Also. References Asay TP. Duncan BL. the treatment may be helpful. That is. Penguin. although they alone may not always be sufficient to produce the desired result.

J Consult Psychol 14:436–445. Greenberg RP: Freud Scientifically Reappraised: Testing the Theories and Therapy. 1991 Greenberg RP: Common psychosocial factors in psychiatric drug therapy. 1977 Wachtel PL: Action and Insight. 1936 Wachtel PL: Psychoanalysis and Behavior Therapy: Toward One Integration. American Psychological Association. Am J Orthopsychiatry 6:412–415. 1973 Frank JD. New York. Johns Hopkins University Press. Washington. Miller SD. pp 297–328 Lambert MJ: Implications of outcome research for psychotherapy integration. 1957 Rosenzweig S: Some implicit common factors in diverse methods of psychotherapy. Am Psychol 47:1102–1114. Basic Books. 1996 Frank JD: Persuasion and Healing: A Comparative Study of Psychotherapy. Goldstein MR. New York. Baltimore. nondirective and Adlerian therapy. MD. Frank JB: Persuasion and Healing: A Comparative Study of Psychotherapy. 1975 Prochaska JO. MD. 3rd Edition. New York. J Consult Psychol 14:239–245. 1950a Fiedler FE: The concept of an ideal therapeutic relationship. Wiley. J Consult Psychol 21:95–103. Norcross JC. Duncan BL. New York. DiClemente CC: Changing for Good. Johns Hopkins University Press. Singer B. in The Heart and Soul of Change: What Works in Therapy. DC.Essential Ingredients for Successful Psychotherapy 241 Fiedler FE: A comparison of therapeutic relationships in psychoanalytic. 1950b Fisher S. DiClemente CC. Luborsky E: Comparative studies of psychotherapies: is it true that “Everybody has won and all must have prizes”? Arch Gen Psychiatry 32:995–1008. Revised Edition. Edited by Hubble MA. Guilford. 1992 Prochaska JO. pp 94–129 Luborsky L. Baltimore. Avon. 1995 Rogers C: The necessary and sufficient conditions of therapeutic personality change. Norcross JC: In search of how people change: applications to the addictive behaviors. Basic Books. Edited by Norcross JC. in Handbook of Psychotherapy Integration. 1987 . New York. 1999. 1992.

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Echemendía. Ph.D. Ph. he face of America is rapidly changing. Historically. Sue and Sue 1999). It seems appropriate for the field to engage in a critical self-examination and ask the basic question “Is contemporary psychotherapy an effective means of treating the culturally different?” Data suggest that many groups that are culturally different from the upper.9 Brief Psychotherapy in a Multicultural Context Rubén J. psychotherapy models have arisen from largely Eurocentric worldviews (Hall and Barongan 1997.and middle-class American mainstream significantly underuse 243 T . Joël Núñez. relatively little emphasis has been placed on examining the role of cultural and ethnic differences in current psychotherapeutic approaches. Given the ever-increasing cultural and ethnic diversity in the United States. Although many strides have been made in the advancement of psychotherapy outcome and effectiveness studies.D. the need for multicultural awareness and competence among fields providing human services is greater today than ever before.

and expectations as practiced in the United States are not understood and accepted by all. the data also suggest that many doctoral-level psychotherapists generally perceive themselves as insufficiently trained to work with culturally different clients (Allison et al. Cuéllar and Paniagua (2000). Ponterotto (2001). techniques. not a final state to be achieved. In this chapter. Therefore. Many scholars have asserted that traditional forms of psychotherapy were developed within a context in which “normality” was characterized by the beliefs.244 The Art and Science of Brief Psychotherapies mental health services. this chapter is not intended to be a thorough review of the many considerations that should be taken into account in multicultural counseling. especially in brief psychotherapies. Bernal and Castro 1994). cognitions. and socioeconomic statuses. it is a point worthy of attention. Baruth and Manning (1999). there appears to be a cultural chasm between the providers of mental health services and many of those intended to be the users of said services. and the contribution of these factors to the underuse and premature termination of mental health services by ethnic minority mental health consumers. observations. Cultural Context of Psychotherapy A fundamental issue that lies at the heart of multicultural clinical competence is the understanding that psychotherapy itself is not a universal phenomenon and that its general tenets. We also discuss psychotherapists’ lack of training with these populations and the inevitable discomfort this generates when treating individuals from different cultures.to . such as Atkinson et al. sexual orientations. 2) the need for awareness and integration of the client’s worldview into clinical conceptualizations and treatment planning. Interested readers are encouraged to review comprehensive texts. Topics briefly discussed in this chapter include 1) a consideration of the culture-specific context of psychotherapy. we attempt to help bridge that chasm by providing a brief introductory overview of issues that are often overlooked in the psychotherapeutic treatment of culturally different peoples. and 4) multicultural clinical competence as a continual process. It is simply a starting point. Because of space limitations. (1998). 3) the importance of therapist awareness of his or her own worldview and its relationship to that of the client. and perspectives of middle. and Sue and Sue (1999). Although this point may appear to be obvious to most clinicians. At the same time. 1996. These seemingly marginalized groups are composed of not only racial and ethnic minorities but also members of divergent religious denominations.

assessment. Subsequently. he or she will divulge highly personal information about himself or herself to a stranger. it is not uncommon for Latino individuals to report religious “visions. viewed as abnormal or pathological. models. by corollary. 2001).Brief Psychotherapy in a Multicultural Context 245 upper-class heterosexual European and European American men (Lee and Ramirez 2000. In fact. homosexuality was categorized as a disorder in DSM-II (American Psychiatric Association 1968) largely because American culture defined homosexual behaviors as aberrant. A lack of clinical awareness at this basic level may lead to misunderstandings. and a therapist who is gregarious and self-disclosing may be viewed as unprofessional. and diagnosis (Cuéllar 1998. from initial interview to case conceptualization. many more) should lead clinicians to consider the framework within which psychotherapy operates and to appreciate that for many groups of people. Also. or even alien. It is critical. Some cultures emphasize formality in interpersonal relationships. albeit a professional one. significant deviations—including cultural ones—from these norms of character and conduct are. By extension. Harris et al. and even mistaken assignment of client psychiatric disorders at every level of therapeutic contact. . 1995). and expectations that form the foundation of psychotherapy may be viewed as novel. Americans expect that when a person enters psychotherapy. premature termination. methods. who does not reciprocate by disclosing personal information about himself or herself.” Do these visions constitute pathological hallucinations or culture-specific expressions of religious beliefs? These simple examples (of which there are many. such as some Asian Americans. culturally dissonant. the criteria of what constitutes normality and the means by which normality is assessed have been set in a culture-specific context. For instance. Sue and Sue 1999). For example. some scholars and researchers have argued that the therapeutic context itself may unwittingly mirror society’s cultural power arrangements (Ponterotto 2001). The subsequent elimination of the diagnosis in DSM-III (American Psychiatric Association 1980) clearly points out the sociocultural aspects of diagnoses. the paradigms. or recent Eastern European immigrants. they may consider it insulting or dehumanizing that the therapist does not respond in a personal manner. therefore. Native Americans. This approach may be viewed as inconsistent with the cultural beliefs of many other groups. In fact. that the clinician who differs culturally from his or her clients be aware that clients may not share the same suppositions about therapy and its expectations. Another powerful example was the nineteenth-century classification by many in the medical community of the ostensibly deviant behavior of runaway African American slaves as a mental disorder (Szasz et al. The reverse is also true. by definition.

in their quest for brevity. Refusal to answer these questions would create a breach in the therapeutic alliance and likely lead to premature termination. Both the therapist and the supervisor also benefited from the experience. therapists may be ill prepared to serve as ongoing social supports for culturally different clients who find themselves isolated from the social mainstream. The therapist’s supervisor (an otherwise highly competent United States–born and United States–trained psychologist) indicated that these personal questions should be avoided because they would lead to problems in the transference relationship. began psychotherapy with a Spanish-speaking client during his training. or nation. socioeconomic group. During the initial interview. the therapist replied that a failure to answer the questions would be viewed as disrespectful to the client and neglect to establish the warm relationship that is the basis of Latin cultures. The notion of therapy as a focused. instrumental process. Awareness of the Client’s Worldview Baruth and Manning (1999) defined worldview as the sum of an individual’s experiences along with social. born in Cuba. interpersonal relationships between individuals. The senior author of this chapter. Cuban and Puerto Rican cultures are similar in many regards. and the therapy progressed nicely. The client was from Puerto Rico. One similarity in the culture is that of being simpático—encouraging warm. for example. The cultural expectations of clients may particularly clash with basic assumptions underlying the brief therapies. The very notion of time as a scarce commodity to be saved is peculiar to Western cultures (Sue and Sue 1999) and may clash with clients’ own expectations of an ongoing bond with a supportive figure. which emphasize expressive and relational values (Spence and Helmreich 1978). He asked questions that would otherwise be considered personal and not to be answered within traditional psychoanalytic/psychodynamic perspectives. Also. racial or ethnic group. The therapist’s desire to answer the questions was viewed as a “countertransference issue. Baruth and Manning believed that it is imperative that a client’s worldview be incor- . The reference group may consist of family or community.” However. the male patient was very much interested in the therapist’s background. religious. and political beliefs and attitudes held in common with other members of the individual’s reference group. fits far better with traditionally masculine gender roles than feminine ones. The questions were answered.246 The Art and Science of Brief Psychotherapies An example may help bring these issues to light. with the client experiencing significant relief from the issues that led him to seek therapy.

Brief Psychotherapy in a Multicultural Context 247 porated into the clinical conceptualization and treatment of clients. an important aspect of treatment with culturally different clients will include the readjustment of client worldviews to embrace the social. it is not acceptable for minors to be kept from school for such reasons. and background by therapists has been cited as a factor associated with inadequate mental health service delivery to multicultural populations. p. (Baruth and Manning 1999. lifestyle. Because many brief therapies attempt to assess client concerns and achieve a focus for intervention within the first session. the counselor needs to learn the meaning of that response in the client’s worldview. First. The clinician may acknowledge the Latino cultural tradition that encourages younger family members to participate in the care of elders but also should inform the family that in the United States. lesbian. they need to ensure that an assessment of the cultural contexts of presenting concerns is a formal part of treatment planning (Steenbarger 1993). Indeed. The dangers of failing to appreciate clients’ worldviews. For example. They stated that a client’s worldview is an overriding cognitive frame of reference that influences most human perceptions and values. gay. are magnified in the brief therapies. bisexual. therapists run the risk of applying “one size fits all” treatments to presenting problems. Patterson 1996). however. To understand an individual’s response to a situation and to avoid a communication breakdown. the recognition that a client’s worldview and sociocultural environment influence behavior has become more acceptable within American psychotherapeutic circles (Cuéllar and Paniagua 2000). come several new challenges. and transgendered groups. 9) A lack of understanding about a client’s attitudes. a Latino family in treatment may report that a child has missed 3 weeks of school because the child’s primary responsibility is to care for an elder who is ill. In some instances. values. If brief therapies are to be culturally sensitive. including racial and ethnic minority groups. knowledge of and respect for a client’s cultural worldview should not imply that universally regarded pathological behavior such as spousal abuse or child neglect is acceptable under the guise of culturally sanctioned practices (Fontes 1995. With this growing acceptance on the part of psychotherapists and counselors. political. it is difficult to imagine that a therapist could truly enter into a client’s unique cultural history and experience in the span of a brief assessment phase of treatment. Fortunately. and cultural realities that exist in the United States. Negy 2000). present in any psychotherapy. and members of nonmainstream religious groups (Baruth and Manning 1999. Perhaps a compromise can be reached that would .

Sue and Sue 1999). A tenuous balance must constantly be struck between viewing each client as part of the larger group(s) to which he or she belongs and seeing the client as an individual who may sometimes feel. There is a potential danger of placing an individual so far within a cultural context that the characteristics and idiosyncrasies of the client in question are lost in cultural stereotypes and overgeneralizations. the client’s worldview.g. In this manner. As a rule. It also requires a serious commitment from the clinician outside of sessions to learn about the cultural groups for which he or she intends to provide services (American Psychological Association 1993. yet most ignored. It is not the client’s responsibility to provide protracted pedagogical instruction for the therapist (Lee and Ramirez 2000). it is safe to assume that there is as much. elements of the therapeutic relationship is the lack of recognition on the part of the therapist of his or her own worldview and how it may differ from. middle-class Anglo-American therapist and recent . if not more. it is a crucial element in providing culturally competent mental health services. awareness of the importance of a client’s worldview in treatment implies more than a healthy curiosity about the client’s cultural background within sessions. therapists concerned with brevity should be aware of the danger of stereotyping clients as a result of overgeneralizing the cultural information they may have acquired about the group(s) with which the clients identify while ignoring the variability that exists within those groups. accommodation is made and respect accorded to the clients’ worldview but not at the cost of the child’s welfare or the laws of the land. Also.248 The Art and Science of Brief Psychotherapies allow the child to attend school and to assist in the care of the elder in the afternoon. Careful attention to the maintenance of a collaborative relationship within brief therapy is vital toward assuring that therapists and clients are not operating from opposite sides of a cultural chasm. variability within a cultural group as between cultural groups. think. Although striking the balance may appear to be difficult.. and in some cases even be antagonistic to. At the same time. These differences may occur when the client and therapist are from distinctly different cultures (e. The Therapist’s Worldview: Acknowledging Differences Within the Therapeutic Relationship Perhaps one of the most significant. and behave in ways that are not consistent with the prevailing knowledge about that group.

at best.) in the Midwest. concern for their career paths. issues of culture and worldview are not restricted to the traditional “ethnic minority” . and her desires to help them raise her grandchildren in an “appropriate manner. and religious framework that may adversely influence the therapeutic relationship can have devastatingly negative effects on treatment outcome (Cuéllar 1998). Sue and Sue 1999).” She found herself often worrying about them. The supervisor had a worldview that valued independence. it is important for therapists to be aware of their worldviews just as it is important for therapy supervisors to be aware of their worldviews. She expressed concern for them. biases. increased anxiety. ignorance of the fact that the therapist is an individual embedded within a social. The presumption that the therapist can somehow be objective enough to enter into each session being able to bracket out his or her own long-standing perceptions. political. She had limited contact with Jewish people and had little knowledge of Jewish culture. cultural. and trained in the Midwest. New York. The members of the therapy team who were observing (including the author) felt that the patient was expressing traditional Jewish beliefs about family relationships and the role of the mother within a Jewish family. Those familiar with the culture argued that such a position would lead to culturally inappropriate behavior.E. Her approach to treatment would have required the patient to become “independent” and live a life distinctly apart from her children. The therapy supervisor and a team of therapists were observing the therapy of a middle-aged Jewish mother through a one-way mirror. The supervisor was born. The student therapist was from New York City. First. The supervisor felt that the patient was being “overly intrusive” and pathological in her desires to “control” her family. An interesting example of this occurred during training for one of the authors (R. This example underscores several important issues. and likely premature termination. simplistic (Gopaul-McNichol and Brice-Baker 1998. the supervisor described the situation as “enmeshed” and pathological.J. Cuban therapist and Puerto Rican client). experiences. to her credit. prejudices. The supervisor. The patient was describing to the therapist her relationship with her grown children.Brief Psychotherapy in a Multicultural Context 249 Mexican immigrant) or when the client and therapist are from presumably similar cultures (e. As noted earlier. In both cases. and attitudes about others in order to impede these from interfering in treatment is. as well as many other permutations. accepted that she might not be able to fully appreciate the situation because she had little knowledge of the patient’s worldview. lived. as an individual and within the family structure..g. When it became clear that the woman’s children had no objections to the mother’s role. and the patient was from Long Island.

there is the real danger of consciously or unwittingly viewing the disorders of culturally different clients as being curable only if they were to discard their own culturally maladaptive ways of being and adhere to those of the therapist’s culture (Lee and Ramirez 2000). Even if people are born with the capacity to be tolerant of differences in others.g. consider an AngloAmerican male therapist and his African American female client. Another example may prove useful. Although both Cuban and Puerto Rican people speak Spanish.250 The Art and Science of Brief Psychotherapies categories. but we rarely pay attention to differing worldviews when the client and therapist appear to be similar. who is conflicted about accepting a lucrative job that would require her to leave her family’s hometown and move to a distant city. these inclinations must be actively discovered and challenged in order to facilitate respect for those of differing cultures and worldviews (Atkinson et al. or ethnocentrism. As therapists. have reported that being immersed in and favoring one’s own cultural values and beliefs is a normal phase of personality development that one simply does not naturally outgrow (Baruth and Manning 1999. a black Spanish-speaking therapist with a white Southern Baptist client). Second. Differences are found in language. and so forth. Similarly. they differ in several important ways. identification with “Spanish” roots. the cultures differ in many ways. must be aware of their worldviews and examine ways in which their worldviews may interfere with their assessment and treatment of patients. migration patterns. Studies exploring the construct of cultural encapsulation. Ponterotto 2001). Cultural differences exist even within relatively mainstream groups in the United States. history of colonization. Baruth and Manning 1999. Therefore. Cross 1991. However. and those who train them. 1998. many people tend to view their own cultural values and beliefs as preferable and/or superior to others. particularly if one examines sociocultural status and racial differences within those cultures. For example. Gopaul-McNichol and Brice-Baker 1998). therapists. emphasis on education. a Puerto Rican therapist who was born to a relatively wealthy family in Puerto Rico and who completed her education in the United States may have a very different worldview from that of a mixed-ancestry Cuban refugee who arrived in the United States during the Mariel boat lift. We noted earlier in this chapter that Cuban and Puerto Rican cultures are relatively similar. In the absence of this. He might believe that this conflict could be eliminated if she ignored her culturally valued . we are comfortable recognizing differences when they are readily apparent (e. A white Cuban therapist who immigrated to the United States during Castro’s revolution may have a very different worldview from that of a dark-skinned Puerto Rican client who came to the United States to improve his family’s economic situation..

to behaviors and standards that can be unconditionally accepted. The brief therapist may rapidly diagnose depression and introduce the idea of antidepressant medication. There are limits. However. even though supported by research evidence. may on occasion conflict with the dictates of a particular culture. These include things such as acceptance of abuse of one individual by another or a requirement that people relinquish the right to have individual identities with unique thoughts and feelings. in which therapists—in their concern for brevity—may promote symptom relief over goals that are more relevant for culturally different clients. The introduction of emotional exploration and treatments for diagnosed conditions—so basic to the therapist’s worldview—may frustrate the legitimate needs of such clients. becoming convinced that there is no elephant in the room—the divergent worldviews of therapists and clients may be used as a valuable therapeutic tool to elicit and subsequently process potentially beneficial transferential and countertransferential material that may relate to the effects of gender. socioeconomic status. for example. sexual orientation. clinicians need to decide in each case where to draw the line between being sensitive to cultural practices and offering support for basic human rights. and so on as they impinge on the client’s well-being (Cuéllar and Paniagua 2000. a male homosexual client with issues surrounding self-acceptance and the lifelong perception of others’ condemning his sexuality may benefit greatly from clinical interaction with a heterosexual male therapist who might represent society’s institutionalized discrimination against homosexuality. At the same time.Brief Psychotherapy in a Multicultural Context 251 stance of familism and collectivism in favor of an individualistic frame of reference that typifies his own culture. Such beliefs. The worldview encompasses a set of beliefs about the conditions leading to human discomfort and unhappiness. religion. although it may be broad. It is important to admit that psychotherapy itself does have a cultural component and a worldview. For example. Instead of ignoring “the elephant in the room”—or worse. for international clients to regard the therapist as a wise doctor who can provide advice on life questions. for example. it should be acknowledged that certain culturally sanctioned beliefs are incompatible with basic assumptions of psychotherapy treatments. It is not unusual. heedless of the cultural implications of such diagnosis and treatment of mental illness. Sue and Sue 1999). This potential clash between the values and worldviews of therapists and clients is accentuated in brief therapy. this is likely not to be the case if the therapist is unwilling to explore his own ingrained views about his own identity and his beliefs and biases about homosexuality and instead vehemently insists that he perceives his client . even in psychotherapy. race or ethnicity. In the end.

” The dual problem with this view. there exists a large group of mental health professionals who were trained long before issues of culture were ever discussed as a serious topic (Baruth and Manning 1999. Data suggest that many psychotherapists do not perceive themselves to be competent enough to work with culturally different clients. multicultural perspectives are relegated to optional courses within graduate curricula or are covered during one session (many times at the end of the semester) in graduate seminars in a disjointed manner. Often. yet most have made few changes. Some have called for the development of multicultural clinical competencies at the graduate and professional levels for psychotherapists. Sue and Sue 1999). and professional organizations (American Psychological Association 1993. Bernal and Castro 1994. inadvertent forms of sexism or insensitive comments and behaviors may occur in therapy as a result of the therapist failing to come to grips with his own identity and experiences that differ from. Hall and Barongan 1997. Many scholars and researchers have additionally pointed to the underrepresentation of culturally diverse faculty in graduate training programs as a predictor of the lack of minority courses offered. and practica. the danger of ignoring what may be an important identity to the client. the client’s (Ponterotto 2001. Lee and Ramirez 2000). the minimal amount of culturally diverse research produced by the program. is. Second. researchers. Multicultural Clinical Competence at the Graduate and Professional Levels Failure to recognize the importance of cultural variables and to integrate multicultural perspectives into clinical practice may be directly attributable to the lack of attention paid to these issues in graduate training and continuing education programs despite multiple admonitions to the contrary by many mostly ethnic minority scholars. assessment. making it difficult for students to integrate the material presented with other required topics such as psychopathology. In addition. even though many of them have received some form of multicultural training at the graduate and postgraduate levels (Allison et al. Either or both of these hypothetical circumstances can lead to breakdowns in the therapeutic alliance and thus are counterproductive to clinical change. 1996). and may be antagonistic to. Lee and Ramirez 2000). subtle. just like any other client. representing a key determinant of many of his attitudes and behaviors. first.252 The Art and Science of Brief Psychotherapies as “nothing more than a person. of course. Some training programs have made significant strides in including multicultural training as part of their curricula. and the limited number of cul- .

Conclusion We live in an increasingly diverse society that demands appropriate mental health services for all of its constituents. Hall and Barongan 1997). Sometimes minority culture practitioners assume that they are competent to work with minority populations because they themselves are from an underrepresented group. it just means that we are aware of our limitations and have some work to do. The integration of multicultural perspectives into psychotherapy (and assessment) may seem daunting and at times overwhelming. we believe that the inclusion of cultural perspectives into each of the psychotherapeutic approaches discussed in the previous chapters of this book will improve the effectiveness of these approaches with culturally different clients. retained. little. it is easier to maintain the status quo than it is to question our abilities and perhaps change our practices. Perhaps the best type of additional training is seeking supervision from a colleague who is recognized to be expert in the area. This training is suggested for all clinicians. . In the manualization of many brief therapies. is not an indication of multicultural competence. the entire notion of manualization runs counter to the notion that therapy should be tailored to the varied needs. Ultimately. values. Minority status. As we all know. and worldviews of patients. attention has been paid to multicultural competence. An accurate self-appraisal will generally lead to the conclusion that we are fundamentally unprepared to provide adequate services to individuals who are culturally different than we are. and graduated from the program (Bernal and Castro 1994. it is the responsibility of therapists to assess their own comfort level and self-perceived competence in working with diverse populations. especially in short-term therapies. it means that our most responsible course of action is to refer the patient. If therapists lack multicultural competence in time-unlimited therapies. However. if any. reinforcing the impression that cultural factors are not central to the helping process. and consultation with other professionals more knowledgeable in the particular culture. In other cases. This recognition does not make us “bad” or incompetent. attending workshops and seminars. In some cases. This is particularly true in the case of linguistic differences. they can hardly be expected to be able to integrate culturally informed assessments and interventions into their short-term work. Indeed. in and of itself.Brief Psychotherapy in a Multicultural Context 253 turally diverse students recruited. not just those from the majority culture. it may mean that we need to secure additional training in the form of self-study.

1998 Baruth LG. 1980 American Psychological Association: Guidelines for providers of psychological services to ethnic. Janzen H. 2nd Edition. integrating multicultural competencies into training and practice can contribute to increasing effective mental health service delivery among culturally different clients. 1996 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. San Diego. NJ. CA. 1991 Cuéllar I: Cross-cultural clinical psychological assessment of Hispanic Americans. 1998 Cuéllar I. Washington. Edited by Andrews J. References Allison KW. 1968 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. Upper Saddle River. Treatment. Manning ML: Multicultural Counseling and Psychotherapy: A Lifespan Perspective. Temple University Press. 2nd Edition. Saklofske D. CA. DC. Prof Psychol Res Pr 27:386–393. Barongan C: Prevention of sexual aggression: sociocultural risk and protective factors. pp 391–414 . Echemendía RJ. Academic Press. American Psychiatric Association. CA. Crawford I. Philadelphia. et al: Predicting cultural competence: implications for practice and training. MA. 1993 Atkinson DR. Echemendía R. The continued failure to do so can only portend the development of an even wider chasm between psychotherapy and multicultural populations in the United States and provide a disservice to the very people who place their care in our trust. Castro FG: Are clinical psychologists prepared for service and research with ethnic minorities? Report of a decade of progress. 2001. Sue DW: Counseling American Minorities. 1994 Cross WE: Shades of Black: Diversity in African-American Identity. Sage. Merrill. 3rd Edition. 1995 Gopaul-McNichol S. Am Psychol 49:797– 805. Paniagua FA (eds): Handbook of Multicultural Mental Health. Boston. American Psychiatric Association. et al: Cross cultural competencies and neuropsychological assessment. 1998 Hall GCN. 1997 Harris J. and Training. Morten G. 2000 Fontes LA: Sexual Abuse in Nine North American Cultures: Treatment and Prevention. in Handbook of Psychoeducational Assessment. Washington. Am Psychol 52:5–14. Academic Press. DC. PA. and culturally diverse populations. Brice-Baker J: Cross-Cultural Practice: Assessment. Ardila A. Am Psychol 48:45–48. McGraw-Hill. San Diego. New York. 1999 Bernal ME. 5th Edition.254 The Art and Science of Brief Psychotherapies Just as contemporary research has focused on identifying common elements across psychotherapies that facilitate clinical change. Thousand Oaks. linguistic. J Pers Assess 70:71–86. Wiley.

Helmreich RL: Masculinity and Femininity: Their Psychological Dimensions. pp 121–150 . 1999 Szasz TS. Sage. Austin. in Sociology: Exploring the Architecture of Everyday Life. University of Texas Press. Wiley. 2nd Edition. Paniagua FA. CA. 1995. Thousand Oaks. 2000. CA. and future of multicultural psychotherapy. CA. 1993 Sue DW. and Antecedents. Thousand Oaks. 2000. Sue D: Counseling the Culturally Different: Theory and Practice. in Handbook of Multicultural Mental Health. Edited by Cuéllar I. New York. pp 279–309 Negy C: Limitations of the multicultural approach to psychotherapy with diverse clients. Chambliss WJ: Constructing difference: social deviance. J Couns Dev 72:8–15. J Couns Dev 74:227–231.Brief Psychotherapy in a Multicultural Context 255 Lee RM. Academic Press. 1996 Ponterotto JG: Handbook of Multicultural Counseling. Ramirez M: The history. 2001 Spence JT. 3rd Edition. Edited by Cuéllar I. Correlates. Edited by Newman DM. CA. San Diego. current status. 1978 Steenbarger BN: A multicontextual model of counseling: bridging brevity and diversity. pp 439–453 Patterson CH: Multicultural counseling: from diversity to universality. Reiman J. in Handbook of Multicultural Mental Health. Pine Forge Press/Sage. Paniagua FA. Academic Press. San Diego.

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or many patients with a variety of disorders. the judicious use of medications in addition to brief therapy allows for—or accelerates— change. 2000. brief psychotherapy by itself is very effective. whereas psychological and interpersonal deficits are more effectively treated with psychotherapy (reviewed in Barlow et al.D.g. 2000).. Dewan and Pies 2001. Keller et al. agitation) generally respond better to medications. Furthermore. However. and 2) biological symptoms (e. Dewan. for some patients. several excellent studies that have compared psychotherapy alone and medications alone with the combination of psychotherapy and medication have reported two important findings: 1) the combination is better than either treatment alone. Therefore. sleep disturbance. M. therapists need to constantly update their biopsychosocial understandings of their patients and repeatedly evaluate whether their patients would be best treated by psychotherapy or medications or a combination of both.10 Combining Brief Psychotherapy and Medications Mantosh J. 257 F .

g. During the course of brief therapy. Severe symptoms (e. benzodiazepines) or even the micropsychotic episodes of borderline personality disorders (e. eaten. targeted medications to treat their disabling anxiety (e. Evaluating the Need for Medication During the initial evaluation.. dealing directly with their trauma or fears may exacerbate patients’ symptoms and make them unable to function in therapy and/or in their lives. I present guidelines for the use of medications and then address the psychological effects on the therapist and patient of adding medications to brief psychotherapy.g. patients often return to the active focus of brief psychotherapy. These patients may benefit from short-term.258 The Art and Science of Brief Psychotherapies In this chapter. I recommend steps to foster effective collaboration among the treatment triad—the patient. After medication makes symptoms (e. The reverse also has been shown to be true: after a trial of antidepressants was ineffective. Psychotherapy by itself is a complex procedure that requires great skill to perform competently and has the potential for both benefit and harm.g. short-term use of benzodiazepines for a patient experiencing panic attacks) more manageable. patients exhausted and drained from days of not having slept. the brief therapist may decide that medications could be helpful. Adding another modality (medication) and another partner (a prescribing physician) requires an even greater sensitivity and skill on the part of clinicians. or taken a break from struggling with the consequences of acute trauma may benefit from a few days of medications to help them sleep before they can actively participate in brief therapy. brief therapy was helpful in treating residual symptoms and nonresponders. Furthermore. Similarly. Medication should be given only if patients’ symptoms prevent them from being active in psychotherapy at that moment. nonresponders and patients with significant residual symptoms may benefit from a trial of medications.g... adding specific brief therapies may help prevent relapse. This is supported by a small study of depressed patients who were unaffected by cognitive therapy but then responded to an antidepressant. such as cogni- . the therapist. and the prescribing physician—so that change can proceed both efficiently and forcefully. sleep medications for a person with an acute grief reaction. panic attacks) may prevent a willing patient from actively engaging in brief behavior therapy. At the end of brief therapy. Medication could quickly relieve these crippling panic symptoms and allow for psychotherapy to proceed. low-dose antipsychotics). even after medications have been effective..

significantly fewer relapses occur than when effective medications such as the serotonin reuptake inhibitors are discontinued). with patients fre- . Medications also should be considered when the patient expresses a strong preference for them. nurturing act that feeds their dependency needs or validates their suffering as genuine. and can have a shorter treatment course (e. Some patients view it in a positive way because they believe that the therapist “must be interested in me as a person and not just in my symptoms” or that the therapist thinks that “I am competent enough to do it by myself.” Angry and dependent patients. because they consider it a caring.Combining Brief Psychotherapy and Medications 259 tive-behavioral therapy for patients with depression and exposure and response prevention for obsessive-compulsive disorder (reviewed in Dewan and Pies 2001).. may regard it in a negative way because the therapist is believed to be withholding support or prolonging their agony. Some patients derive a psychological benefit from being given medications.g. Therefore. generally has fewer side effects. This is particularly potent because our culture vigorously promotes the false idea that a pill can fix everything. however. I have also seen patients who are desperately denying the severity of their symptomatology and dysfunction.g. when behavior therapy for obsessive-compulsive disorder is stopped. 10 sessions of interpersonal psychotherapy for depression compared with a yearlong course of antidepressant medications). These feelings may contribute to noncompliance with both medications and brief therapy. In some disorders. Other patients may see the prescription of medications as an imposition of external control or as a statement by the therapist that they are not strong enough to solve their problems by themselves. brief psychotherapy also is more effective than medications in preventing relapse (e. therapists must carefully assess their own reasons for considering medications and also look for reactions—both obvious and covert—and the psychological meaning that these medications have for each particular patient.. brief psychotherapy alone is as effective as medication. It is appropriate to educate them on their options and to point out (if this pertains) that for many conditions. Psychological Meaning of Medications The old proverb “A cigar is not just a cigar” can be rephrased as “A pill is not just a pill.” perhaps even psychotic (Dewan 1992). Not offering medications is also interpreted in different ways. Offering them medications means that they have to confront their worst nightmare and acknowledge that they are “very sick.” Each patient and therapist brings his or her own unique and personal attitudes toward medications.

One of my patients was vehemently opposed to taking Stelazine (trifluoperazine) (“I hate it! It reminds me of my sister Stella. Some patients so overvalue their medication that they will carry around the unfilled prescription as a soothing—and often very effective!—good-luck charm or transitional object. “That’s fine. also may have an idiosyncratic association to the name of a medication. be they fear. Fostering Collaboration Within the Clinical Triad: Patient. Some therapists are absolutely opposed to certain medication groups. because they believe that they are addicting. Collaboration between disciplines has many advantages for the patient and the collaborators. or sexual attraction toward a particular patient. collaborative treatment is common. like patients. Doc?” (Dewan 1992). and Prescribing Physician Setting the Stage Although psychiatrists can provide both therapy and medications themselves. controlling. saying. right. which may lead to better adherence to medications and a more active participation in brief therapy. may unfairly dictate the addition of medication as a way of distancing. and she is doing well. or even punishing the patient. and they will deprive patients of them even when they could be enormously helpful and prescribed safely.”) but graciously agreed to take an equivalent drug. Although these distortions may not be overtly discussed in brief therapy. in particular. The patient receives greater amounts of time and expertise. most brief therapy is done by nonphysician therapists. also have strong biases and reactions toward the use of medications. hate. Collaboration provides an invaluable opportunity for mutual professional and emotional support on an ongoing basis but especially at times when the patient is in crisis. most commonly the benzodiazepines. Because medications are frequently combined with therapy.260 The Art and Science of Brief Psychotherapies quently asking for a specific (but sometimes unrelated) drug because “my friend takes it. The therapist’s unrecognized feelings (countertransference). It will make me mellow. . Mellaril (thioridazine). Therapists. Nonphysician Therapist.” Other patients feel that they are not being taken seriously or are not considered sick enough or even that the therapist thinks that they are faking their symptoms. therapists must be aware of the possibilities because they sometimes serve as a powerful distraction from the agreed-on therapeutic focus. Psychotic patients.

” If the patient shares something “in confidence.” warning bells should go off (Meyer and Simon 1999). the research data that suggest medications are likely to be helpful. however. This recommendation may. “Don’t tell the doctor. the patient says to the therapist. and then cross-refer to each other. The patient needs to know that all information will be shared between the collaborating partners and should sign appropriate releases at the outset. Unless the patient is psychotic. The therapist should summarize the need for medications by describing to the patient the troublesome clinical symptoms that are to be targeted.” or to the psychiatrist. the therapist and psychiatrist must clarify the important elements of their practice: clinical orientation. D. learn to respect. “I do not feel like my therapist listens to me. but sharing this with the patient is inappropriate and almost always antagonizes the prescribing physician. who will provide what part of the treatment. Patients need to be told explicitly that the consultation may or may not result in medication being prescribed. Furthermore. even though I tell him that I am taking it. but I have stopped taking his horrible medication.” The therapist may in fact be correct that the patient needs an antidepressant and may indeed have a strong preference for a particular one. we will ask Dr.Combining Brief Psychotherapy and Medications 261 It is essential that the therapist and the psychiatrist build a mutually trusting and respectful relationship.” For example. one that clearly recognizes the special and differing skills that each partner brings to the collaboration (Balon 2001). “If you agree. be conveyed directly to the physician. I present the medication consultation as a useful adjunct to the more important work being done. which is the brief therapy. Given this scenario. There is no place for “secrets. D to consult with us on whether medications may be helpful to you at this time” is more appropriate than “I think you should be taking Prozac. each should provide someone from his or her own discipline). how to contact each other after hours and during vacation coverage (the therapist and psychiatrist should not cover each other. and the fact that medication is an added resource to improve outcome. so I don’t tell her about cutting myself. I will refer you to Dr. it is common and even advisable for a therapist and a psychiatrist to get to know the backgrounds and practices of. Making the Referral It is important that the therapist set the stage appropriately with the patient about the referral for medication consultation. and confidentiality. It is important that the referral be for an open-ended consultation and not for a specific medication. how emergencies will be handled. .

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It is best when therapists obtain a consultation proactively rather than when they feel they are “stuck,” at a therapeutic impasse, or when they have discovered the patient to be at high risk for suicide or homicide and want to “pass on the risk.” Sometimes a managed care company pressures a therapist to get a medication consultation if it judges that the patient is not improving quickly enough. When the psychiatrist agrees with the therapist and decides to recommend medications, it is important to again explain the reasons to the patient and then to discuss the available options. Given that patients have very personal reactions to medications, the specific medication is best chosen as a collaborative venture to improve adherence. How to take the medication, expected improvement, and potential side effects are clearly described and perhaps even written down so that both the patient and the therapist are aware of them. The schedule for follow-up appointments is also clearly spelled out (Himle 2001). After the first or second appointment, the psychiatrist and therapist need to communicate directly, share their impressions, and agree on a treatment plan. The psychiatrist is expected to support the psychosocial treatment plan and refrain from recommending changes in it to the patient (e.g., “I think that solution-focused therapy would be more effective than the behavior therapy you are receiving.”). If the psychiatrist thinks that a change is needed, he or she may recommend this only to the therapist. Furthermore, the consulting psychiatrist must not be drawn into discussing psychotherapeutic issues with the patient. Likewise, therapists are expected to fully support the medication regimen and are an important ally in improving adherence. If the therapist disagrees with or wants to change medications, this discussion should take place directly with the physician and not indirectly through the patient. Similarly, specific questions from the patient about medications should be referred back to the prescribing physician (Himle 2001). It takes a great deal of effort to keep the clinical triad “on the same page.” Interdisciplinary tensions, honest differences in clinical approach, and a lack of time to keep regularly in touch all potentially stress the therapist–psychiatrist relationship. Some patients with a penchant for splitting may quickly aggravate the situation. The functional triad often deteriorates into two parallel dyads. Besides the obvious (i.e., the therapist and psychiatrist must invest in an ongoing relationship), we have found that doing the initial medication evaluation as a triad (i.e., having the therapist present) allows for all parties to evaluate the symptoms, agree on a treatment plan, and assign roles in an open manner, thereby minimizing distortions and fostering a collaboration that allows for maintaining the focus on therapeutic goals.

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Conclusion
Therapists who provide long-term therapy will inevitably have some patients in combined treatment. Even therapists who primarily do brief therapy will have some patients who are taking medication. Many patients will be receiving both treatments from the start (e.g., a psychotically depressed patient taking an antipsychotic and/or antidepressant plus undergoing brief cognitive or interpersonal therapy). Some patients will start in brief therapy alone and may need medication added (e.g., a benzodiazepine being added to brief behavior therapy to control panic attacks) during the course or at the end of therapy for residual symptoms. Others will benefit from brief therapy after a course of medications. For instance, some patients with obsessive-compulsive disorder are initially unable to tolerate the treatment of choice, exposure and response prevention behavior therapy. Medications are used to bring symptom relief before the addition of exposure and response prevention therapy, which usually is then better tolerated. It is heartening that several brief therapies and medications are available to bring relief to our patients. It is essential that therapists and psychiatrists know the biopsychosocial aspects of their patients well, recognize the powerful treatment options that are available, and tailor their treatments (singly and in combination, either simultaneously or sequentially) to the patient’s needs according to the available clinical and research evidence rather than maintain an old-fashioned adherence to ideology. When combining brief therapy and medication, therapists must be aware that the simple dyadic relationship (therapist–patient) of psychotherapy alone has been converted into two complex, overlapping triadic relationships—therapist–patient–medication and therapist–patient– prescribing psychiatrist—each with powerful psychological dynamics. A thoughtful and often energetic engagement is required by all partners to avoid the many potential pitfalls and to benefit from the rich promise of medications and collaborative care.

References
Balon R: Positive and negative aspects of split treatment. Psychiatric Annals 31:598– 603, 2001 Barlow D, Gorman J, Shear K, et al: Cognitive-behavioral therapy, imipramine, or their combination for panic disorder. JAMA 283:2529–2536, 2000 Dewan M: Adding medications to ongoing psychotherapy: indications and pitfalls. Am J Psychother 66:102–110, 1992

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Dewan MJ, Pies RW (eds): The Difficult-to-Treat Psychiatric Patient. Washington, DC, American Psychiatric Publishing, 2001 Himle J: Medication consultation: the nonphysician clinician’s perspective. Psychiatric Annals 31:623–628, 2001 Keller M, McCullough J, Klein D, et al: A comparison of nefazodone, the cognitive behavioral analysis system of psychotherapy, and their combination for the treatment of chronic depression. N Engl J Med 342:1462–1470, 2000 Meyer D, Simon R: Split treatment: clarity between psychiatrists and psychotherapists, part 2. Psychiatric Annals 29:327–332, 1999

11
Evaluating Competence in Brief Psychotherapy
John Manring, M.D. Bernard Beitman, M.D. Mantosh J. Dewan, M.D.

A trainee reads this book, observes experts present the art and science
of their craft, uses each of the six specific brief therapies in work with a few patients, and is carefully supervised. Is the trainee now demonstrably competent in brief psychotherapy? As part of a broader movement in medicine to use outcome-based and evidence-based treatments, there is now increasing pressure from the public (via government), health insurers, and certification agencies to show that trainees actually learn what training programs claim they are teaching them. But how does one dependably test competence in something as complex and varied as psychotherapy? We have much yet to learn about which aspects of these psychotherapies are essential for them to be effective, which are sufficient, and which go beyond what is required to facilitate therapeutic change in a patient. As a result, we cannot 265

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define what the minimum is that one must do to have a successful outcome. Thus, we are left with two problems: what to measure and how to measure it. In this chapter, we present some basic building blocks in these two areas that may allow programs to construct their own competence assessments.

What to Measure: Enumerating Skills Needed for Competence in Psychotherapy
Lacking research data and consensus, the field has turned to experts to help define those skills believed to be important for effective brief therapy (e.g., the American Association of Directors of Psychiatric Residency Training [AADPRT] Psychotherapy Task Force, the Association of Directors of Psychology Training Clinics [ADPTC] Practicum Competencies Workgroup). In Chapter 12 (see Tables 12–1 through 12–3), Steenbarger et al. present a list of skills deemed common to all schools of brief therapy and match them to the three phases of therapy. Another set of general psychotherapy skills, based on the work of the AADPRT group1 and Beitman and Yue (1999), which are deemed necessary but not sufficient, include abilities to manage boundaries, to develop a therapeutic alliance, to listen, to handle emotions and be understanding, to use supervision, to deal with obstacles to therapy, and to intervene therapeutically. Some believe that the more specifically we can define these skills (e.g., the ability to begin and end a session on time as a specific task within the global skill “to manage boundaries”), the more likely psychotherapy will be effectively taught and learned. For this reason, several groups have distilled general psychotherapy skills into their smallest identifiable units, the acquisition of which will lead to competent performance of psychotherapy (Bienenfeld et al. 2000). Three examples are illustrative: • Boundaries—The ability to 1) establish and maintain a treatment frame (e.g., setting schedules and sticking to times, dealing with outside agencies and relationships), 2) establish and maintain a professional relationship, 3) protect patient privacy and confidentiality, and 4) appropriately handle financial arrangements with the patient

1

AADPRT Psychotherapy Task Force: David Goldberg, Ron Reider, Ron Krasner, and Lisa Mellman. Further refined by Carol Bernstein and New York University faculty and Hinda Dubin and University of Maryland faculty.

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• Therapeutic alliance—The ability to 1) establish rapport and a therapeutic alliance with the patient, 2) enable the patient to actively participate in the treatment, 3) recognize and repair disturbances in the alliance, and 4) establish a treatment focus • Techniques of intervention—The ability to 1) maintain focus in treatment; 2) confront a patient’s statement, affect, or behavior and assess his or her response; and 3) assess readiness for and manage termination of treatment To convert the previously mentioned necessary skills into skills sufficient for effective generic brief therapy, sets of additional skills have been prescribed by several groups. One, by Steenbarger et al., is presented in Chapter 12 (Tables 12–1 through 12–3); another, by Beitman and Yue (1999), requires • Verbal interventions—The ability to use a broad array of verbal interventions, including providing hope, reassurance, information and guidance, reflection, interpretation, and confrontation; focus the patient; promote the patient’s identification of feelings, thoughts, and behavior patterns; and encourage and reinforce change • Identifying patterns—The ability to use inductive reasoning to generalize from specific pieces of information to patterns of behavior, feelings, or thoughts that fit the patient; are viewed by both the patient and the therapist as needing change; and, once changed, lead to the desired outcome • Strategies for change—The ability to 1) recognize three stages of change—relinquishing dysfunctional patterns, initiating functional patterns, and maintaining functional patterns; 2) identify the three orders of change—helping a patient do something different, helping a patient alter a pattern in a way that generalizes to new situations, and teaching the patient to change patterns without the help of a therapist; 3) identify the five domains of patient functioning—emotion, cognition, behavior, interpersonal, and system; and 4) use a sufficient breadth of techniques in each domain to help patients change Additional skill sets will be required for the specific brief therapies. For instance, the AADPRT group (L. Mellman and E. Beresin, co-chairs, AADPRT Psychotherapy Task Force [AADPRT-list@aadprt.org]; July 3, 2000) suggested the following abilities for brief cognitive-behavioral therapy: 1. State the cognitive model. 2. Socialize the patient into the cognitive model.

Significantly. State and employ knowledge of cognitive triad of depression. The implication. to certify competence. 8. Identify common cognitive errors in thinking. Listing specific skills sufficient for effective brief therapy is an important start toward learning these skills. 5. and patient feedback). How to Measure It: Tools to Assess Competence Competent is defined as “suitable. these questions remain to be answered by empirical research. or whether some critical mass or percentage of the skills is required for competence. 6. In the following subsections. we still must decide which skills are essential. It may be helpful to think about competence on a continuum of increasing skill as described in the Dreyfuss model of skill acquisition (Figure 11–1). Once we agree on the list of skills necessary for competence in psychotherapy. agenda setting. therefore. 10. is that a trainee may not need to master all the skills of psychotherapy to be considered competent. competent is a skill level midway between novice and expert. 4. sufficient. Unfortunately. 7. follow-up and self-help sessions appropriately with patients when terminating active therapy. we list seven methods most applicable to the brief psychotherapies. Written Examination The familiar printed or computer-based multiple-choice questionnaire examination is designed not only to sample easy-to-recollect facts and knowledge but also to evaluate a candidate’s understanding of the sub- . bridging to prior session. whether all skills are necessary. Use behavioral techniques as a tool in therapy. how do we assess adequacy or competence in each of these skills? The Accreditation Council for Graduate Medical Education (ACGME—the parent certifying body for all medical specialties) constructed a “toolbox” of 13 “best methods” for evaluating competence in all aspects of medical education (ACGME Outcomes Project 2000). capsule summaries. homework review. or adequate” (Webster’s 20th Century Unabridged Dictionary. Identify and elicit automatic thoughts. 2nd Edition). Use structured cognitive model activities (mood check. 9.Plan booster. Use dysfunctional thought records as a tool in therapy.268 The Art and Science of Brief Psychotherapies 3. Use activity scheduling as a tool in therapy.

some choices Lectures. 269 .Evaluating Competence in Brief Psychotherapy Novice Learning issues Isolated facts. supervised work Simulations Realistic work setting Self-managed Evaluation method Real evaluations. patient centered Specialized training. laboratories. Competence on a continuum of increasing skill as described in the Dreyfuss model of skill acquisition. laboratories. faculty control Tests ➝ Beginner Some synthesis. identity ➝ Proficient Professional norms. portfolios Self-assessment. socialization Work-related markers ➝ Expert Internalized Learning methods Seminars. self-control ➝ Competent Independence. internalized standards Figure 11–1.

In a computer adaptive test. Criteria for evaluating . Checklist Evaluation Checklist evaluation consists of using a list of essential or desired specific behaviors. and the test is stopped when the candidate has clearly proven his or her ability.65 to 0.. Drawbacks can arise in the expense of equipment. Multiple-choice questionnaire examinations are universally used for in-training examinations and for initial certification. Although the multiple-choice questionnaire is useful for testing knowledge. probing for reasons behind the diagnoses.g. Comparing test scores on in-training examinations with national norms can identify strengths and limitations of individual trainees to help them improve.270 The Art and Science of Brief Psychotherapies ject. Ontario. acquiring informed consent. selection of a focus. Reliability ranges from 0. use of strategies for change. Trained examiners would follow a standard protocol to orally examine a single case or a “portfolio” of the trainee’s work (discussed in “Portfolios” later in this chapter). initial interview. Chart-Stimulated Recall Oral Examination A chart-stimulated recall examination uses the trainee’s case record. fewer test questions are needed because statistical rules are programmed into the computer to quickly measure the examinee’s ability. activities..” or tapes as the basis of a standardized oral examination of the care provided. or steps that make up a more complex skill. termination) could provide an accurate record of a trainee’s skills and decision making. Research supports the usefulness and reliability (0.88. interpretations of clinical findings. Checklists are developed by expert consensus. history taking) and for interpersonal and communication skills when directly observed by a trained rater. For instance.8) of checklists for evaluation of patient care skills (e. No data are available on chart-stimulated recall and psychotherapy. Comparing test results aggregated for trainees in each year of a program can be helpful to identify training experiences that might be improved.g. however. it cannot evaluate subtle interactions and cannot be the sole device used to assess competence in psychotherapy. this is a promising technique for both evaluation and teaching. and treatment plans. and examining a sufficient number of stages of therapy in an adequate range of patients in the various schools of therapies. Examiners rate the trainee with a well-established protocol and scoring procedure. different versions of which are currently operational at McMaster University (Hamilton.7–0. a trainee’s videotapes from several stages of treatment (e. “process notes. Canada).

end of a clinical rotation) and derived from multiple sources of information (e. Written comments allow evaluators to explain their ratings. scores can be highly subjective and biased with untrained raters.. It typically contains written documents (e. a summary of . direct observations or interactions. With global ratings. However.. It can include statements about what has been learned. trainees. fair= 3.g..g. review of work products or written materials). their evaluation by checklists may not be valid. ability to establish rapport or a therapeutic alliance) represent complex abilities that cannot be broken down into their component skills.Evaluating Competence in Brief Psychotherapy 271 performance benefit from descriptive “anchor points. input from other faculty. we present several lists of skills believed to be essential for brief therapy.. and we are left in the uncomfortable position of saying that we cannot define competence precisely but that “we recognize it when we see it. Global ratings of patient interviews directly observed by trained examiners are currently used in the oral examination portion of the American Board of Psychiatry and Neurology certification process and in many training programs. tasks.” If carefully constructed and tested for validity and reliability. Some simple tasks lend themselves to checklists..g. Global Rating of Live or Recorded Performance Global rating forms are distinguished from other rating forms in that 1) a rater judges general categories of ability (e. or patients.. poor=4). good =2.. interpersonal and communication skills) instead of specific skills. outstanding= 1.g. Reliability and validity improve when standards are created and “anchors” (i. but many of them (e. its application.g.g.e. or behaviors. Rating scales are numeric but presented as qualitative indicators (e. a log of therapies used.” Earlier in this chapter and in Chapter 12. In graduate psychotherapy training. Therefore. global rating forms can be easily constructed and can be completed quickly. and remaining learning needs and how they can be met. examples of behaviors or attitudes) for each point on the scale are provided. and 2) the ratings are completed retrospectively based on general impressions collected over time (e. a portfolio might include a log of diagnoses treated. Portfolios A portfolio is a collection of products prepared by the trainee that provides evidence of learning and achievement related to training goals. logs and transcripts) but can include video or audio recordings. checklists could be effective tools for evaluating actual or recorded trainee therapy sessions (see “Portfolios” later in this chapter).

standardized patients). Technical experts then create scripts for standardized patients or computer-based simulations and add. make life-threatening errors without hurting a real patient. when feasible. a quality improvement project. role-playing situations (e. peers.g. and obtain instant feedback so that they can correct a mistake in action. Simulations and Models A wide array of simulations used for assessment of clinical performance closely imitate reality and allow examinees to reason through a clinical problem. descriptions of ethical dilemmas faced and how they were handled. The contents of a portfolio do not have to be standardized. clinic staff. and families). co-trainees. superiors. Experts set the scoring rules. To build a simulation. subordinates. Also daunting is the administrative complexity of distributing and collecting the forms and quantifying the results meaningfully. it is difficult to design a single questionnaire for rating a trainee’s brief therapy skills that is appropriate for use by supervisors. Simulation formats have been developed as paper-and-pencil branching problems (patient management problems). However. the 360-degree evaluation instrument has the potential to become a powerful tool. primary outcome data. or a recording or transcript of interactions with patients. and families. computerized versions of patient management problems called clinical case simulations. Used in business. military. and combinations of all formats. A portfolio is also one of the best tools for combining teaching with assessment of continuity-of-care concerns that are the essence of psychotherapy. clinical experts craft scenarios from real patient cases to focus on specific skills. automated scoring rules. Simulations can be used to rate performances on clinical problems that are difficult to evaluate effectively in other circumstances.g.. patients. patients. and education settings. because each is looking for something different from the trainee and is likely to use and understand language differently.272 The Art and Science of Brief Psychotherapies the research literature reviewed when selecting a treatment option. because the purpose is to show individual learning gains relative to individual goals. this method is an appealing one for collecting reliable. with sufficient resources. Developing protocols for assessing such portfolios would be crucial to the reliability of such assessments. Simulations are expensive to create.. However. None . clinical team simulations. 360-Degree Evaluation Instrument The 360-degree evaluation instrument is a questionnaire completed by multiple people in a trainee’s sphere of influence (e.

the Working Alliance Inventory and the Truax Empathy Scale) and the technical competence of the therapist (e. Evaluating Competence in Brief Therapy Today Brief psychotherapy is a complex interplay of interpersonal skills and therapeutic techniques played out during 2–20 sessions over weeks to a year.. Knowledge is tested by giving multiple-choice questionnaire examinations with clinical vignettes (e. of necessity. However. live patient . 2003). more comprehensive approach may include • Periodic examinations at the end of a module. they culled the essential ones to construct a portfolio (see below).g. 2001) will power the development of sophisticated and useful computerized simulations of the more subtle aspects of therapy in the future. Columbia Psychodynamic Competency Psychotherapy Test [formerly called Columbia Psychodynamic Psychotherapy Skills Test]). they teach seven brief therapies using manuals (except for psychodynamic therapy) to increase fidelity. We expect that the rich literature on simulation and gaming (Meyers et al. then. How. the Cognitive Therapy Scale and the Therapist Strategy Rating Form for interpersonal therapy. For supportive. All skills are not tested. yet a trainee completing the portfolio requirements satisfactorily will likely be at least competent in the brief therapies and will. From their detailed list of skills considered important for competent psychotherapy. At McMaster University in Canada. Audioor videotaped sessions are assessed in weekly supervision.. quarterly. interpersonal.. cognitive-behavioral. trainees present recordings of early and late sessions for each specific therapy. can we best use the ACGME toolbox and the list of skills developed by experts to certify competence? A review of several models that already exist may be helpful. Weerasekera 1997. simple clinical vignettes to assess the recognition and handling of psychotherapeutic phenomena have been incorporated into the Columbia Psychodynamic Psychotherapy Skills Test (a multiple-choice examination).g. Another. 1999.Evaluating Competence in Brief Psychotherapy 273 are currently available for assessing the nuances of psychotherapy. or yearly. which are evaluated with standardized scales for rating the therapeutic relationship (e. Clinical skills can be tested cross-sectionally by administering an oral examination based on tapes. and family therapy. No obvious method is available to adequately evaluate the art and science of an ongoing relationship.g. Beitman and Yue (1999) took a very different approach at the University of Missouri. Satish et al. have learned a great deal in the process.

. another Likert-scaled questionnaire of 32 thoughts. resistance. via tapes) of specific skills. A vignette from the trainee’s own cases of how a stressor became the focus of brief therapy. every 3 months 2. Trained examiners score the examination according to a standardized protocol. Two examples of finding a focus with two patients in brief therapy 10. Both a trainee and a patient version of the Working Alliance Inventory. A Counseling Self-Estimate Inventory.g. a “minimum clinical expectation” of having treated three patients with at least two specific brief therapies) and the objective demonstration (e. • Weekly supervision. or behaviors that may lead to boundary violations 5. A description of five boundary violations with specific cases based on an Exploitation Index. to show use of cognitive therapy 8. Two analyses of psychotherapy sessions in which the trainee categorizes each intervention as to mode of response as well as his or her own intention. Supervisors can improve the validity of their evaluations by using “anchored” global ratings to periodically assess knowledge and clinical skills. behavioral or solution focused). Two brief descriptions of the relationship between past experiences and current difficulties.g. Copies of two dysfunctional thought records from the trainee’s own patients and two examples illustrating cognitive distortion. Global Evaluations of Trainee Change (a single-item rating scale from “very poor” to “excellent”) by supervisors every 3 or 6 months . and countertransference 7. to show understanding of psychodynamics 9. which create a permanent record of requirements met (e. or simulations. these analyses are then compared with later sessions for the variety of interventions used 4. which are used to probe reasons behind formulations and treatment plans. a powerful tool for teaching and evaluating therapy because it is a longitudinal process..274 The Art and Science of Brief Psychotherapies interviews. feelings.. Examples from the trainee’s own practice of transference.g. a 37-item Likert-scaled questionnaire about the trainee’s attitudes and skills. a 12-item rating scale to assess the state of the therapeutic alliance 3. Trainees can be rated on both a list of key skills common to all therapies and skills specific to a therapy being practiced (e. and a vignette of psychodynamic as well as cognitive-behavioral patterns evident in the same case 6. • Portfolios. Examples of portfolios assembled over long periods of training and used at the University of Missouri at Columbia include 1.

Fortunately. Puerto Rico. 2000 Meyers H. and recorded samples that show specific technical skills (especially helpful when anchored by successful patient outcomes) and by tolerating the ambiguity (we hope for only a bit longer) that has been an integral part of our profession from its inception. Until then. 2001 Weerasekera P: Postgraduate psychotherapy training. Yue D: Learning Psychotherapy. Finally. as controlled trials inform us about which psychotherapies are effective for which problems and the behaviors and techniques specific to those psychotherapies.1. New York. Acad Psychiatry 24:2. March 2003. research consistently shows that patients do benefit from brief therapy. global ratings of ongoing supervision. We are optimistic that we will also be able to construct sophisticated computer models of the psychotherapeutic situations that call on those essential skills. p 24 . Simulation and Gaming 32:156–174. Barach P: Assessing and improving medical competency: using strategic management simulations. Carbondale. even when provided by trainees. September 2000 Beitman BD. The reliability of portfolios would be enhanced by training raters in the application of rating criteria to each aspect of the portfolio to ensure consistent evaluation across portfolios. DxR Development Group. Copyright 1992–1999 Satish U. This could help show that a trainee’s competence correlates with good patient outcome. WW Norton. References ACGME Outcomes Project: Toolbox of Assessment Methods. Klykylo W. to assess ability for supportive psychotherapy The portfolio can be strengthened by the addition of two 360-degree evaluations (or at least the subjective and objective rating of patient outcome).Evaluating Competence in Brief Psychotherapy 275 11. Knapp V: Process and product: development of competency-based measures for psychiatry residency. Version 1. we will likely be best served by a broad-based portfolio with multiple-choice questionnaire examinations. San Juan. Dorsey K. 1997 Weerasekera P: Competency-based psychotherapy training: can we get there? Annual meeting. Acad Psychiatry 21:122– 132. American Association of Directors of Psychiatric Residency Training. despite all the distracting “noise” in the system. Benz E: DxR Patient Simulation Software. we will become more specific about what we expect from a competent trainee. and improving medical care: the use of simulation technology. IL. 1999 Bienenfeld D. Two vignettes in which the supervisor stops the tape or transcript and the trainee provides an empathic summary of what the patient has just said. Streufert S.

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Part III Overview and Synthesis .

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Steenbarger. readers have encountered six models of brief therapy that have been successfully incorporated into training efforts in the mental health professions. brief interpersonal therapy. we can observe the broad scope of the art and science of short-term intervention. and cognitive-behavioral couple therapy.D. In cognitive therapy. rather. Roger P. The brief therapies are not fundamentally different from time-unlimited therapies. Ph. Dewan. behavior therapy. 279 I .D.12 Doing Therapy. Briefly Overview and Synthesis Brett N. and a high level of involvement and activity on the parts of therapists and patients. significant overlaps are found among these models. solution-focused brief therapy.D. maintenance of a well-defined therapeutic focus. Mantosh J. Greenberg. n the preceding chapters of this book. timelimited dynamic therapy. As we suggested in Chapters 1 and 8. Ph. their uniqueness stems from their efforts to accelerate change processes through careful patient selection. M.

280 The Art and Science of Brief Psychotherapies This concluding chapter draws on the six preceding models to derive a set of core competencies underlying brief therapeutic practice.. in this book. It is hoped that this effort can inform efforts in the mental health professions to assess both therapist skill and the outcomes of training efforts. the alliance between therapist and patient is a hallmark of effective therapy in all examined therapies. In cognitive and behavior therapies. and Levenson. Although each specific model of brief work necessarily uses these competencies differently. Thus. A term used by many of the authors is collaborative. goal setting is accomplished in a highly interactive. Therapists work collaboratively with couples to identify the facets most central to their presenting complaints and establish these as targets for change. cementing the alliance even while framing the instrumental ends of treatment. Chapter 5. for example. In Chapter 7. collaborative mode. . The brief therapist must have the same core relationship skills that are essential to all forms of counseling and therapy but—given time limitations—must be particularly active in fostering and maintaining the positive working alliance. Baucom and colleagues. Stuart’s description of the short-term therapist as a “benevolent expert” captures the dual roles of support agent and change agent in brief work. if not impossible. noted. the short-term therapist actively involves patients in all phases of planning and implementing the treatment. as Stuart. Once achieved. and the methods used. these focal changes can spill over to other areas of life for individuals and couples. for example. Chapter 6. in this chapter. as stresses are lowered and methods for dealing with problems are learned. Indeed. the rationale for therapy. Skill Set One: Relationship Skills As Greenberg emphasized in Chapter 8. brief work becomes very difficult. we propose that the following three skill sets form the backbone of what it means to be a competent practitioner of brief therapy. issues highlighted in Manring et al. the alliance is furthered by efforts at psychoeducation: educating clients about the origins of problems. when patients lack an interpersonal history and attachment styles conducive to the ready formation of an alliance. Chapter 11. in solution-focused brief therapy. The various chapter authors note that their approaches to change hinge on the formation of a successful working alliance between therapist and client. noted that it would be overwhelming for therapists and clients to tackle all facets of a couple’s life.

Doing Therapy. These can be modeled and assessed in training. the short-term therapist must be a facilitator. In Chapter 9. Briefly 281 This active alliance building includes the core therapeutic elements of warmth. It is truly.” Rather. the active. the brief therapist must be able to foster an environment conducive to such endeavors. Echemendía and Núñez raised cultural awareness as an important dimension of brief work. creating a sense of safety that permits the exploration of difficult issues. and behavior. the absence of time constraints tends to remove an element of urgency from therapists. however. for example. Once again. traditions. caring laurels rather than actively pursuing a collaborative stance. Collaboration proceeds differently when English is the second language of a client or when clients come to therapy with significant concerns over the ability to trust a therapist who is of a different gender. a tangible sense of teamwork that pervades each phase of the helping process. providing a broad heuristic of “to do” tasks in brief work. can court only unfavorable outcomes. Brief work goes beyond these elements. This confers both advantages and disadvantages. even in settings where much of the work may not be limited by time. in the tradition of cognitive therapy. As Baucom et al. (Chapter 7) observed in brief couple work. feeling. On the positive side. Table 12–1 proposes several markers of competent collaborative behavior across the brief therapies. learning therapy without time pressures allows one to cultivate basic relationship skills—in essence. learning to crawl before walking or running. To accomplish this.” in which the participants share responsibility for examining and modifying patterns of thought. or nationality. given the diverse expectations that clients bring to therapy. Students in the mental health professions often learn their craft in a mode in which time is not an explicit dimension of treatment planning. and empathy found among all successful helping interventions. Brief therapy done well is not done to a patient but with that patient. in fostering an active sense of involvement among clients. The resulting matrix may be particularly helpful for readers’ self-assessments. allowing them to rest on their warm. collaborative stance of short-term work transcends a mere avoidance of racial or cultural stereotypes or broad and bland efforts to convey “respect. This table and Tables 12–2 and 12–3 organize the markers by the proposed stages of change in brief work outlined in Chapter 1. “collaborative empiricism. The competent brief therapist who notes conflicts in this client’s home must be educated in the ways such domestic difficulties are . Blindly applying a cognitive-behavioral model of assertiveness training to a client whose cultural background emphasizes deference to one’s elders. patients are treated as informants who educate therapists in their distinctive values. On the negative side. race. genuineness. and beliefs.

282 The Art and Science of Brief Psychotherapies Table 12–1. Markers for relationship skills among brief therapists Engagement phase ✓ The therapist shows warmth. ✓ The therapist avoids complicated and negative transference reactions and resistances rather than focusing on them. is to make the patient an expert in his or her own treatment. without necessarily completing it. ✓ The therapist actively engages clients in educative efforts that describe how problem patterns are formed and how they are addressed in therapy. eliciting an understanding of how the unique educational. The collaboration that marks the conduct of short-term work also permeates its completion. ensuring that change efforts move at a pace appropriate to each client. Consolidation phase ✓ The therapist maintains a collaborative stance even at the end of treatment. Baucom and associates observed in Chapter 7. cultural. is to help couples become better observers and evaluators of their own pat- . ✓ The therapist actively seeks the involvement of clients in framing the means and ends of therapy. A key task of the therapist. ✓ The therapist is actively educated by clients. drawing on the analogy between brief therapy and family practice. and empathy toward clients in the process of eliciting background information. racial. The goal. opening the door for intermittent visits and ongoing assistance as needed and desired. responding helpfully to client questions and concerns. making sure that there is a shared understanding of the responsibilities and expectations for both parties. It is accepted that short-term intervention starts a change process. and gender backgrounds of clients help to shape their experience. for example. In Chapter 2. genuineness. Stuart (Chapter 5) and Levenson (Chapter 6). Ensuring that clients are cocontributors to therapeutic means and ends is an important way in which the cultural congruence of helping efforts can be sustained. successfully resolved in the client’s culture. Beck and Bieling described this as teaching patients to become their own therapists. Hembree and colleagues noted in Chapter 3. socioeconomic. as therapists replace the notion of “termination” with the idea of intermittent visits. that “cure” is not the goal of therapy. An examination of the six clinical chapters finds broad acceptance of the idea that brief therapy does not treat all problems or all facets of personality. Discrepancy phase ✓ The therapist actively delivers and solicits feedback during the course of therapy. noted the value of intermittent therapy in brief interpersonal therapy and time-limited dynamic therapy.

In such cases. actively gathering information that aids in determining the appropriateness of short-term work and in selecting and maintaining a proper therapeutic focus. tend to require sustained intervention and support. Whereas longer-term practitioners may involve themselves in lengthy analyses of resistances and transference reactions. brief therapists are apt to view such forays as counterproductive. Greenberg echoed the research-supported notion of noxious effects stemming from an overemphasis on transference interpretations. Skill Set Two: Instrumental Skills The active goal orientation of brief therapy was a universal theme sounded by the chapter authors. By making the therapist available for “booster” sessions. in which transference is actively used. must be able to engage the therapist in an examination of relationship patterns. Stuart’s notion of dividing therapy into two phases. Steenbarger noted. In Chapter 4. in Chapter 5. that solution-focused brief therapists take pains to define goals in user-friendly ways. Similarly. short-term treatments maintain a collaborative stance even after regularly scheduled meetings have ended. Stuart observed that brief interpersonal therapists assiduously avoid the development of transference responses that would detract from the primary therapeutic focus. brief treatments may be useful but will be conducted in sequential fashion to achieve long-term ends. brief therapy is not appropriate for all clients or presenting concerns. acute and maintenance. rupturing the teamwork essential to successful short-term work. with the maintenance phase extending indefinitely to accommodate future needs. Briefly 283 terns. so as to ensure client participation in tasks and exercises. In Chapter 8. in Chapter 6 on time-limited dynamic psychotherapy. As we noted in Chapter 1.Doing Therapy. Even in time-limited dynamic psychotherapy. as in the dialectical behavior therapy of Linehan (1993). The brief therapist must be task focused. Such an emphasis may unwittingly contribute to a divide between therapist and client. identified several factors that guide the application of her brief work. the emphasis is not on an analysis of the transference but on the provision of new relationship experiences in the here and now. . Finally. Levenson cited research from Strupp and colleagues that found suboptimal therapeutic outcomes in therapies that feature transference interpretation. particularly those that are accompanied by disruptions in the ability to form relationships. In Chapter 6. makes sense in this regard. She stressed that patients must be in a state of emotional discomfort. Levenson. the notion of collaboration also highlights what brief therapists do not do. Chronic and severe problems. for example.

The brief therapist’s assessment of client suitability for short-term work. or if he or she is so emotionally overwhelmed that homework completion is not possible. In Chapter 10. This requires a meaningful degree of client motivation. and solution-focused brief therapy. Dewan cited evidence that indicates superior therapeutic outcomes for particular problems when psychopharmacological interventions (medications) are blended with psychosocial ones (psychotherapy). This can be helpful in working with clients who have had recent traumatic stresses or acute levels of distress associated with panic disorder. make considerable use of homework assignments as part of the helping process. This is intimately linked to the issue of client distress because individuals in a state of discomfort are most likely to possess the motivation to actively sustain change efforts. Stuart. Similarly. noted that brief interpersonal therapy is difficult in patients with Axis II disorders because these disorders often reflect difficulties in forming and maintaining relationships that necessarily interfere with the creation of a ready therapeutic alliance. then brevity is unlikely to be achieved in treatment. The use of a medication to control overwhelming anxiety often makes it possible for a client to focus on the aims of short-term work. In Chapter 1. What is important is that clients who need more extensive intervention be promptly routed to the most promising forms of assistance. Another indication for brief therapy noted by Stuart is client motivation.284 The Art and Science of Brief Psychotherapies and must be capable of forming meaningful relationships. Some of the brief models discussed in the preceding chapters. Certainly. other formulations of inclusion and exclusion are possible. should include a frank discussion with the patient as to whether between-session efforts at change will be feasible. Severity of the presenting problem. In a similar vein. including behavior therapy. therefore. cognitive therapy. and degree of Social support enjoyed by the client. degree of Understanding and motivation possessed by the client. forming the acronym DISCUS: Duration of the presenting problem. Complexity of the problems that are presented. Hembree and colleagues (Chapter 3) cited evidence that suggests a linkage between homework completion and positive outcomes in behavior therapy. If the client is ambivalent about change. we suggested six factors that can form the basis for such an assessment. Indeed. The same DISCUS criteria that are useful in . Table 12–2 proposes that an important marker of competence in brief work is a thorough assessment as to these indications and contraindications for brevity. Interpersonal history of the client. if the client lacks a support system that encourages the completion of homework and the ends of treatment—or if such a lack leads the client to seek ongoing support rather than change efforts from the therapist— therapy is unlikely to be completed in a brief duration. in Chapter 5.

this focus is established through a structured evaluation that ensures that all relevant aspects of client experience are addressed. and their consequences. These structured assessment methods provide a high degree of focus for client evaluations.Doing Therapy. Very often. The second function of a careful assessment is the determination of a concrete focus for treatment. framing contraindications for brief work can be of value in determining when consideration should be given to pharmacological therapies. Discrepancy and consolidation phases ✓ The therapist facilitates activities during each session to ensure that the goal orientation is sustained. also ensure that new therapists cover the most important areas for assessment within their particular modality. ✓ The therapist ensures that goals are stated in a clear and concrete manner. being standardized. Markers for instrumental skills among brief therapists Engagement phase ✓ The therapist conducts a thorough assessment of the factors associated with indications and contraindications for brief therapy. and Steenbarger (Chapter 4) described how formula first-session tasks are used to provide an initial assessment of client goals. their origins. making proper referrals and/or treatment planning decisions with clients who would benefit more from other extended forms of treatment. Briefly 285 Table 12–2. it was the importance of establishing and maintaining a focus to keep therapy time-effective. ✓ The therapist conducts a focused and structured assessment of client concerns to help formulate potential goals for short-term therapy. Such methods. Beck and Bieling stated that the evaluation is conveyed through a cognitive conceptualization diagram that outlines automatic thought patterns. Levenson (Chapter 6) described the formulation of cyclical maladaptive patterns in providing a blueprint for time-limited dynamic psychotherapy. Stuart (Chapter 5) used an interpersonal inventory to assess relationship needs in brief interpersonal work. including redirection when sessions lose their focus. In Chapter 2 on cognitive therapy. If there was one theme that was sounded unanimously among the chapter authors. a training goal consistent with mandates for ensuring therapist competence noted by . summaries of session progress. so that they are unambiguously understood and endorsed by all parties to the helping process. ✓ The therapist enters each session with a mutually understood and flexible “game plan” derived from the client’s goals and ensures that this plan is either implemented as intended or modified as needed. and assignment of tasks and exercises. The idea is to engage in a rapid pattern search (Beitman and Yue 1999) to aid in the formulation of mutual goals that can quickly proceed to an action phase of treatment.

and discussions that can dilute change efforts in time-unlimited treatments. Another caveat. For established patients who do not have significant illness. is that not all clients are ready for active change. This helps ensure that client and therapist share an understanding of the ends of treatment—a factor important to the alliance—but also allows therapy to proceed time-effectively by keeping sessions “on task. This tailored assessment facilitates an efficient movement from assessment to goal formation to intervention. Although this structured approach has clear advantages. Hembree et al. guides the brief therapist once clients have been screened to determine the appropriateness of short-term work. again. or even an exhaustive review of systems. noted that relatively little talking and much doing occur in behavior therapy. (Chapter 7) described the targeting of focal relational patterns. This leaves less room for lengthy digressions. brief therapy is able to achieve brevity thanks to its circumscribed focus and concrete goal orientation. a family physician is unlikely to conduct an entire history and physical. the analogy with family medicine seems apt. is that clients may come to therapy with needs different from those of their therapists. In Chapter 3. Goals are also stated concretely and behaviorally in solution-focused brief therapy. many of the brief therapies are highly structured to ensure such a goal orientation. with interventions aimed at guided behavior change and skills development.286 The Art and Science of Brief Psychotherapies Manring and colleagues in Chapter 11. highlighted by Echemendía and Núñez in Chapter 9. Rather. explorations. Indeed. One of these. Baucom et al. Steenbarger (Chapter 4) noted that solution-focused work is so structured that it can be captured in a flow diagram. unsure of whether they want or need to make the efforts to alter long-standing patterns. a related marker of competence for the brief therapist is the formulation of goals in highly concrete terms. (1994). They come to therapy in a state of relative ambivalence. In no small measure. and cognitive modalities. Beck and Bieling (Chapter 2) similarly spoke of using graded tasks and therapist summaries in cognitive therapy to maintain a concrete goal orientation. important caveats exist. a characteristic also shared by many manualized therapies. including behavioral. with the assignment of specific tasks to maintain the focus between sessions.” Indeed. Clients also may enter therapy too emotionally overwhelmed to undertake the ongoing commitment needed to define and work on therapeutic goals. the assessment will lightly touch on the various systems but focus on the areas of particular patient complaint. A similar assessment. Finally. par- . interpersonal. highlighting the particular areas of client concern. Here. noted in the work of Prochaska et al. with the doing structured by methods such as the creation of anxiety hierarchies for use in desensitization.

if painful. Briefly 287 ticularly needs shaped by their gender or culture. Skill Set Three: Change-Agency Skills In brief therapy. goes to the heart of the matter. To be sure. example of the power of emotional learning. conscious awareness and exercising a relatively direct emotional imprinting. The therapist’s work is thus highly collaborative and userfriendly. Trauma provides an illustrative. to name but two common examples. continuously maintaining a mutually forged game plan for change. the ideal of the therapist-as-blank-screen is replaced by the notion that therapists serve as active change agents. in a sense. In no small measure.Doing Therapy. is the ability to transcend mere talking about problems by creating opportunities to actually experience and rework these. Levenson’s (Chapter 6) quotation from Fromm-Reichmann. bypassing normal critical. often must provide directive guidance even as they maintain strong affective and collaborative bonds. A common theme among the chapter authors is that change efforts are accelerated and enhanced by the creation of active learning experiences both in and out of session. indicating that what patients need are experiences rather than explanations. On the other hand. An important marker for competence in brief therapy. The brief therapist must possess a range of skills that evoke patterns of client thought. The element of time constraint in brief work. The “corrective emotional experiences” identified by Alexander and French (1946) are. Standardized assessments may be so focused that they fail to evaluate the very personal and sociocultural factors that help define a person’s individuality. lends a particular note of challenge. The competent brief therapist must be caring and collaborative in a goal-oriented manner. and behavior in the here and now. brief therapy is not unique in blending these expressive and instrumental demands. On the one hand. the therapist must be especially task focused. the differing forms of brief therapy appear to be “technologies” for generating novel learning experiences for clients. A client who pursues therapy for support and understanding may be frustrated by treatments that consist of highly instrumental tasks and exercises. providing opportunities for an understanding and reworking of these patterns. therapy must actively build and maintain an alliance. Teachers and parents. It is noteworthy that the . as vivid experiences shatter long-standing behavior patterns and even personality characteristics. however. feeling. What this means is that the competent brief therapist walks a continual tightrope. positive traumas. as Table 12–3 suggests. both in assessment and in intervention.

accompanied by their full range of emotion. with the primary locus of change efforts gradually shifting from therapist-initiation to client-initiation. so as to promote an internalization of new skills. and experiential methods. client problems are evoked within the context of the therapeutic interactions. . Cognitive therapists note that a schema. primary mode of change in all of the brief modalities presented in this volume is experiential. Markers for change-agency skills among brief therapists Engagement phase ✓ The therapist elicits existing problem patterns. Discrepancy and consolidation phases ✓ The therapist paces change efforts to provide support and structure and to encourage client autonomy. ✓ The therapist is flexible within his or her repertoire of therapeutic modalities so that if one set of methods does not successfully evoke or rework old patterns. The provision of these powerful learning experiences has two facets. as therapists willingly enter into their clients’ cyclical maladaptive patterns. ✓ The therapist is intimately familiar with one or more therapeutic modalities and the techniques used within these to evoke and rework problem patterns and generate experiences of mastery. to be modified. ✓ The therapist provides multiple contexts for rehearsing changes in client patterns. and experiences. for example. imagery. In time-limited dynamic psychotherapy. then other methods can be readily employed. and behaviors. Tasks assigned in brief interpersonal and solution-focused brief therapies invariably involve facing situations that had proven challenging in the past. Discrepancy phase ✓ The therapist takes active measures to ensure that the affective intensity of sessions is neither so low that it fails to facilitate experiential learning nor so high that it overwhelms patients and frustrates efforts at change. This appears to be a truism across the range of short-term modalities. Cognitive therapy conducts collaborative behavioral experiments to allow patients to directly face their fears. These. none primarily emphasizes dialogue and insight. interoceptive exposure is used to evoke the very sensations of anxiety that have proven troublesome. The first is the evocation of current client patterns. insights. through sensitive inquiry. including their accompanying thoughts. In behavior therapy. feelings.288 The Art and Science of Brief Psychotherapies Table 12–3. first must be activated. Hembree and colleagues (Chapter 3) noted. are doing approaches to therapy and require the therapist to be far more active and directive than is normally the case in time-unlimited treatment.

by itself. this novelty includes the provision of new understandings and new experiences. “The more the patient is affectively involved in therapy. It is not enough to simply activate old problem patterns.” The challenge of the brief therapist is to facilitate sufficient activation of client patterns so that experiences of mastery can result but not so much activation that helplessness is unwittingly reinforced. This fits very well with research cited by Steenbarger. which “creates experiences for a couple so that one or both people may start to question their thinking and develop a different perspective on the partner and/or relationship. the result is likely to be frustration and a sense of discouragement and failure. therapy will bog down if the tasks are too simple and insufficiently challenging. This makes particular sense if we view short-term therapy as a process of emotional learning. (Chapter 3) noted that in their behavioral work. ensuring that therapy is “hot” enough to touch long-standing emotional and behavioral tendencies but not so heated that it threatens to traumatize or retraumatize patients. Maintaining the positive therapeutic alliance even during the heightening of discomfort is a vital marker of skill in brief work. the duration of exposure is an important element in its success.Doing Therapy. Conversely. reflecting an ongoing sensitivity to the experience of clients and the pacing of change efforts. if learning tasks are too challenging. the short-term . The most valuable aspect of successful brief therapy may be its ability to provide opportunities for individuals to directly face their problems and exercise a degree of mastery over these. Bandura (1977) proposed that therapy provides experiences of mastery for clients by providing experiences that are challenging but within their reach. would only replicate what is already occurring in the client’s life. this. Their sessions often extend well beyond the traditional therapeutic hour to facilitate this immersion. Indeed. Rather. Like most learning processes. once these behaviors and their associated thoughts and feelings are stimulated.” Stuart (Chapter 5) noted of brief interpersonal therapy. in which success in solution-focused work was associated with a client shift toward an internal locus of control. The competent brief therapist must titrate this affective involvement. Hembree et al. Such mastery building is an example of the second facet of providing powerful learning experiences: the introduction of novelty during these periods of emotional activation. It also supports the use of guided discovery in the cognitive-behavioral couple therapy of Baucom and colleagues (Chapter 7). the more likely he or she will be motivated to change behavior or communication style. Briefly 289 An important implication of this experiential component of brief work is that short-term interventions generally raise clients’ levels of anxiety and discomfort before offering relief and resolution. As Levenson noted in Chapter 6 on time-limited dynamic psychotherapy.

and emotion-focused therapies. and provide for the novel reworking of old patterns. dedicated training. cognitive. and social sensitivity in brief interpersonal therapy. this also runs the risk of devolving into incoherence. and still later targeting dysfunctional cognitions suggests a lack of focus that almost certainly will prove confusing for clients. Few. role transitions. The toolbox for behavior therapy includes imaginal as well as in vivo exposure methods. It also provides a readymade toolbox for therapists—especially beginning ones—in the form of specific techniques that sustain a treatment focus. Although it is certainly possible for therapists to mix and match techniques from different therapies for a given client. however. data suggest that one particular modality of short-term work is consistently more efficacious than another across the broad range of patients and disorders. emphasizing insight and reworking of relational patterns the next meeting. including those drawn from behavior. if any. Cognitive-behavioral couple therapy embraces a wide collection of tools for change. activity monitoring. requires that competent brief therapists possess a sizable toolbox of methods designed to generate successful novel experiences. This. with insession efforts augmented by homework. Conducting treatment behaviorally for anxiety one session.290 The Art and Science of Brief Psychotherapies therapist must encourage the enactment of new. constructive actions to provide the requisite experience of mastery. interpersonal disputes. Use of interpersonal situations inside and outside of therapy to rehearse new communication patterns and solve problems is a central element in aiding clients to master grief reactions. in the sense of mixing . as Table 12–3 notes. whether a short-term therapist adheres to one approach or another may be less crucial to outcome than the ability to work consistently within some approach. If this fails. behavioral experiments. therapy may be fatally wounded. Without the guidance of a particular method. Echoing Greenberg in Chapter 8. enhance client experiencing. It is difficult to imagine that such “seat of the pants” treatment can provide the purposeful reworking of focal client patterns that is the hallmark of successful brief therapy. the therapist elicits hypothetical solutions by encouraging clients to use their imagination or draw on their observations of others. and coping cards. the therapist elicits novelty first by searching for exceptions within the client’s own behavioral repertoire. In solutionfocused work. The presence of a specific method provides a treatment rationale and expectations for improvement that elicit the cooperation of clients and their commitment to the alliance. The toolbox for cognitive therapists includes the use of graded tasks. Integration. The ability to quickly use such toolboxes when old problem patterns have been activated requires an intimacy with the various models of short-term work that can be obtained only via intensive. dialectical behavior.

the family practice model noted by Stuart is the norm. generally requires the cultivation of experience and expertise in each of these schools and an overarching rationale for the combination. Finally. Some of these contexts are constructed within sessions. Others are structured as out-of-session homework assignments and tasks. One way that short-term therapists facilitate this consolidation of emotional learning is by structuring sessions in an intermittent fashion once initial changes have taken root.” followed by a complete “termination” of sessions.Doing Therapy. skills. relied on events and repeated patterns unfolding naturally in the client’s life. Stuart’s (Chapter 5) aforementioned division of brief interpersonal therapy into acute treatment and maintenance phases is particularly noteworthy in this regard. The goal of the work. structuring initial topics for inquiry. Rather. The successful brief therapist creates a variety of contexts for the enactment of new patterns so that these can be readily internalized. through means such as anxiety hierarchies and repeated behavioral experiments. as noted by Beck and Bieling in Chapter 2. Freud. is to teach patients to become their own therapists. As changes begin. for example. These efforts may begin on an intensive basis during the acute treatment phase of therapy and shift to intermittent visits during the maintenance phase. Change efforts may begin in the therapy office. but they quickly move beyond the four walls to tackle real-life situations. None of the shortterm methods outlined in this text emphasize the notion of “cure. In brief interpersonal therapy and time-limited dynamic psychotherapy. and experiences generated within sessions. whereas brief therapists seem to speed the process through actively prescribed tasks and techniques. not a substitute for them. Briefly 291 methods from various modalities. and proposing betweensession exercises. with later sessions scheduled intermittently to allow for sufficient opportunity to apply insights. Early in treatment. A . the therapist is particularly active in gathering information. clients naturally assume more of the responsibility for generalizing their gains by applying what they have learned from therapy. Such eclecticism is a reasoned integration of modalities. an important element in the practice of brief therapy is the ability to foster the generalization of changes once these have commenced. The pacing of change efforts is thus an important skill for the brief therapist. This contributes to the sense of mastery noted earlier and helps ensure that initial changes truly become part of the client’s repertoire. This change in pacing is accompanied by a movement in the relative locus of change efforts. clients are encouraged to try out new interactional patterns in their social relationships as a means of cementing them. however. The need to generalize change is similar to what Freud described as the “working through” process.

Via workshops. We are unlikely to ever completely unravel the artistry and science of brief therapy. therapies. References Alexander F. we have outlined some of the specific elements that are associated with the skillful practice of brief therapy. nothing substitutes for the observation and mentorship of experienced professionals. This blending of the directive/nondirective and supportive/challenging elements of treatment forms a great deal of the art of short-term work. DiClemente CC: Changing for Good. Ultimately. French TM: Psychoanalytic Therapy: Principles and Applications. Avon.292 The Art and Science of Brief Psychotherapies marker of competence among brief therapists is the ability to both take control and relinquish it. New York. Such a refinement promises much. 1999 Linehan MM: Skills Training Manual for Treating Borderline Personality Disorder. Learning short-term work is not unlike therapy itself: best learned by doing. In this chapter. 1994 . Other formulations of therapist competence are possible and indeed have been proposed (see. Yue D: Learning Psychotherapy. New York. however. New York. and teachers. we may gain a measure of understanding that will enrich the lives of patients and therapists alike. Guilford. We hope that readers and researchers will refine and investigate these criteria. contributing to our understanding of how therapists can serve as effective and efficient change agents. Psychol Rev 2:191–215. anchoring training efforts in graduate and residency programs and enhancing our understanding of how therapist skills are best transmitted and developed. readers can examine their own patterns of practice and acquire new ways of assisting others. WW Norton. Although reading a text cannot be expected to provide expertise in itself. it can start the process of applying new approaches and learning from this application. for example. Conclusion The goal of this book has been to give readers a taste of different brief therapies and their underlying strengths and similarities. 1977 Beitman BD. New York. Norcross JC. To the extent that we can model the best therapists. tapes. encouraging client autonomy while providing the support and structure needed for experiences of mastery. 1993 Prochaska JO. Ronald Press. and direct supervision. Beitman and Yue 1999). 1946 Bandura A: Self-efficacy: toward a unifying theory of behavioral change.

20 interpersonal therapy and. 57 cognitive therapy and. 31 All-or-nothing thinking. of goals in solutionfocused brief therapy. 218 Accreditation Council for Graduate Medical Education (ACGME). 290 Affect. See also Emotions cognitive-behavioral couple therapy and regulation of. 36 American Association of Directors of Psychiatric Residency Training (AADPRT). 144–145 Agenda cognitive-behavioral couple therapy and. and cognitive therapy. 28–32. 199 cognitive therapy and. 283. 267–268 American Board of Psychiatry and Neurology. 42 combined treatment and. 258 core beliefs and. 220–222 interpersonal therapy and. 271 Analogies. 138–139. 99–100 Activity monitoring and scheduling. 34 Acute phase. 31. and couple therapy. and behavior therapy. 218. 16 Acceptance. 221 Animal phobias. 130 Anxiety management training. 266. 140. and couple therapy. 258 Anxiety disorders behavior therapy for. of interpersonal therapy. 61 cognitive therapy for. Academy of Cognitive Therapy. 54–55 Anger. 273 Active form.Index Page numbers printed in boldface type refer to tables or figures. 268. 58–61 293 . 66 Antidepressants. 18–19 dysfunctional behaviors and. 26–27 Agoraphobia behavior therapy and. 65.

26 Beck Depression Inventory. 26 Beck Hopelessness Scale. 32. 88 Beck. 58–61 assessment and. 128. 154 Automatic thoughts. 41 Avoidance. 42–43 Benevolent expert. 26 Behavior. 26 Beck Youth Inventories. 131. and interpersonal therapy. and cognitive therapy. 30 Attachment theory. 196–198 cognitive therapy and. 131 Bandler. 19–20. 6 behavior therapy and. 43 Biopsychosocial model. 222–226 effectiveness of. 130–132 structured methods of. 79–81 cognitive-behavioral couple therapy and. 284–286 Association of Directors of Psychology Training Clinics (ADPTC) Practicum Competencies Workgroup. 127–129. and attachment theory. Suicide and suicidal behavior behavior therapy and focus on. 200–222 . 239 Beliefs. Richard. 71–72. Aaron T. 20. 74–78. 258 Boundaries. 190–191 Behaviorism. and cognitive therapy. 52–55 integration of treatment approaches and. 63–64. 150. 154. 257 Bipolar disorder. 22–23 interpersonal therapy and. 18–19. and couple therapy. 120 Borderline personality disorder cognitive-behavioral couple therapy and. 210–211 generalized anxiety disorder and. 60 time-limited dynamic psychotherapy and. 266 Assumptions cognitive-behavioral couple therapy and. 34 cognitive therapy and experiments in. of psychiatric illness. 129. 260 Biological interventions. Eating behavior. short-term therapist as. 190–191. Safety behaviors.294 The Art and Science of Brief Psychotherapies cognitive therapy and behavioral activation. Differential diagnosis. 183 Behavioral skills deficit model. 28 Beck Anxiety Inventory. 36. 61–81 general description of. 128. 55–57 cognitive-behavioral couple therapy and. 38 dysfunctional patterns of as compensatory strategies. See also Behavioral rehearsal. 39–40. 55–57 case examples of. 131 Assessment. 280 Benzodiazepines. and development of cognitive therapy. See also Case formulation. and skills in brief therapy. 200 Behavioral rehearsal behavior therapy and. Evaluation of ability and willingness to benefit from brief therapy. 35. and interpersonal therapy. 221 combined treatment and. 88 Bateson research group. 266 Anxious ambivalent attachment. Behavior therapy. 16–17. and cognitive therapy.. 53–54 cognitive-behavioral couple therapy and interventions for modifying. 81–82 exposure therapy and. 17 Behavior therapy anxiety management training and. 20 exchange interventions and.

51–82 change agency skills and. 206–207 Breathing training. and behavior therapy. 129 Caring days. See also Solutionfocused brief therapy behavior therapy and. 270–271 Cheerleading. 243–254 definition of. 283–287 intensification as essential characteristic of.Index Brainstorming. 112–116 of time-limited dynamic psychotherapy. 86–87 reasons for current interest in. 125–127. 102 Brief Psychotherapy Program (California Pacific Medical Center). 171–172 Capsule summaries. 135–137. 157–185 California Pacific Medical Center (San Francisco). 215–216. 9–10. 63–64. 36 Catharsis. and interpersonal therapy. 174–184 Case formulation. 166–169. 150–153 of solution-focused brief therapy. 71–72. 44–47 of interpersonal therapy. 287–292 cognitive therapy and. 171–172 Brief therapy. See also Parents and parenting solution-focused brief therapy and. 287–292 Chart-stimulated recall oral examination. 58–59. 280–283 time-limited dynamic psychotherapy and. 96. 74–78. 79–81 of cognitive-behavioral couple therapy. 5–7 instrumental skills in. 231–240 evaluation of competence in. 111–112 Children. 267. 27 295 Care-seeking behavior. 175–176. 170. as cognitive distortion. of competence in brief therapy. and skills for brief therapy. 122–124. and cognitive therapy. 29. and cognitivebehavioral couple therapy. 201 Case examples of behavior therapy. 2–3 therapeutic relationship skills and. 143–147. 257–263 cultural issues in. 107. 223–226 of cognitive therapy. 3 essential components of successful. 207–208. 212–213. 270 Checklist evaluation. 15–47 cognitive-behavioral couple therapy and. and cognitive therapy. and success of brief therapy. 91–93. 265–275 indications for. 161 . 79 Bridge. 236 Center for the Treatment and Study of Anxiety (CTSA). 53. and feedback in solution-focused brief therapy. 202–204. 7–9 interpersonal therapy and. and time-limited dynamic psychotherapy. 106 time-limited dynamic psychotherapy and. 219–220. 71–81 Change strategies. 25. 189–226 combined treatment and. See also Assessment Catastrophizing. 160. 4 effectiveness of. 89. 119–154 learning skills of. 26 Brief Family Therapy Center (Milwaukee). and cognitive-behavioral couple therapy.

263 evaluating need for medication and. See also Cognitive therapy. 25–28 techniques of. and emotional interventions in. 200–222 role of therapist in. cognitive. 44–47 cognitive-behavioral couple therapy and. 96. 258–259 psychological meaning of medications and. 135–136. 47 interpersonal therapy compared with. and completion of homework. 22–25 structure of interviews and. 6. 272 Cognition. 209–216 cognitive therapy and distortions of. 24 cognitive-behavioral couple therapy and. 121 principles of. 260–262. 33–43 . 54 Computer models. 196–198 case examples of. 259–260 Communication. 22–23. 265–275 Complexity. 202–204. and assessment for behavior therapy. 17–22 for depression. 283 Collaborative empiricism. See also Cognitive therapy. 281. 223–226 effectiveness of. 222–226 interventions for modifying behavior in. 25 Columbia Psychodynamic Psychotherapy Skills Test. Couple therapy assessment and. See also Cognitive-behavioral couple therapy for anxiety disorders. dysfunctional patterns of behavior as. 16–17 Cognitive-behavioral couple therapy. 219–220. 36–37 as critical element in psychopathology. 207–208. 97 Comorbidity. 154 solution-focused brief therapy and. See also Medication collaboration among clinical triad in. 131–132. 54. of presenting problem and indications for brief therapy and. 273 Combined treatment. 189. See also Conversations. 280. and cognitive therapy. 35. 198–200 theoretical background of. 195–196 integration of behavioral. 275 Clinical case simulations. and solution-focused brief therapy. 199. 148. 141–144. 20 Competence. 15. 103 Compliance. 222 interpersonal therapy and. 16–17 effectiveness of. 221. Language cognitive-behavioral couple therapy and. 190–195 Cognitive therapy. 190 focus of. 204–209. of psychotherapeutic situations. 23. evaluation of in brief therapy. 222–226 cognitive model of psychopathology and. 215–216. 28 development of. 260–262 between therapist and patient in brief therapy. 212–213. 28–32 case illustration of. Thoughts and thinking brief therapy and cognitive conceptualization. 5 Compliments. 128–130.296 The Art and Science of Brief Psychotherapies Collaboration among physicians and therapists in combined treatment. 56 Compensatory strategies.

90. and solutionfocused brief therapy. 22 dysfunctional behaviors and. 209 Demand/withdraw pattern. 123. 281 worldview of patient and. 42 Core beliefs. 250 Culture current context of psychotherapy and. 100–101. 18–19 diathesis-stress model of. 194. 130. 236. See also Therapist-patient relationship Couple factors. 20–21 Constructivism. 60 Cuba. and interpersonal therapy. 33–34. 198. 209. and couple therapy. 214. 193. 137.Index Consolidation phase. 246. 41. 107. 98. 18–19. of obsessivecompulsive disorder. 108 standardized assessments and. 175. and time-limited dynamic psychotherapy. See also Referrals Consulting breaks. 246–248 worldview of therapist and. 176. 89. 3 interpersonal therapy for. 189–190 interpersonal therapy and. 194 Couple therapy. and timelimited dynamic psychotherapy. 206–207. and cognitive-behavioral couple therapy. 89. 117 Dialectical behavior therapy. 175. See also Communication Coping strategies anxiety and physiological responses to threat. 102–103 Content affect. 222 Diathesis-stress model. in cognitivebehavioral couple therapy. of depression. 70 . 201–202 Covert modeling. of brief therapy. 178. 204. 96–97 Conversations. 139 de Shazer. 139 Control cognitive-behavioral couple therapy and. 287–288 Countertransference. 133–134. 123. Marriage and marital problems effectiveness of brief therapy for. and cognitive therapy. 288 Constructive schemas. 104. and conversations in cognitive-behavioral couple therapy. 282. and cultural issues. 248–252 Cyclical maladaptive pattern. 193 solution-focused brief therapy and internal locus of. 58 cognitive therapy and. 244–246. 176. 261–262. and behavioral rehearsal. 120 297 solution-focused brief therapy and. 285. 183 Decision making. and solution-focused brief therapy. 159. 253 solution-focused brief therapy and multicultural counseling. 29 behavior therapy and. 20. 8. 168. 258–259 core beliefs and. 199 Depression cognitive therapy for. 163–164. 22 Differential diagnosis. 206–207. and time-limited dynamic psychotherapy. 32 Corrective emotional experience. 208. See also Cognitivebehavioral couple therapy. 178. 287 training of therapists and. 144 Contract. 95 Consultation. 205. 28. and cognitivebehavioral couple therapy. 120. 20 effectiveness of brief therapy for. 35 combined treatment and. 208. and combined treatment. 166–169. 252–253. 106–107 Courtship. Steve. 179.

258–259 Exceptions. 136–137 success of brief therapy and. and cultural differences. Milton H. 259 Efficiency. 116 Expectations cognitive-behavioral couple therapy and. 220–222 cognitive therapy and. 53. 105–107. 179. Fear cognitive-behavioral couple therapy and. 199. 288 DISCUS criteria. solution-focused brief therapy and search for. 175. 218–219 cognitive therapy and environmental interventions. 165 Engagement phase. 285. 65–66 cognitive-behavioral couple therapy and. Anger. 237–238 time-limited dynamic psychotherapy and. 39–40 Dysthymic disorder. 214 interpersonal therapy and. 208. 199–200 solution-focused brief therapy and. Number of sessions. Time limit behavior therapy and. 265–275 of need for medication. 162–164. 247 Erickson. as cognitive distortion. 288 Environment cognitive-behavioral couple therapy and. 120 Eating behavior. See also Affect. 97. 192. 274 Discrepancy phase. 205. 93–94 Dysfunctional thought record. 238. 117 Ethnocentrism.298 The Art and Science of Brief Psychotherapies time-limited dynamic psychotherapy and emotional discomfort. of brief therapy. and interpersonal therapy. of brief therapy. 43 time-limited dynamic psychotherapy and. and definition of brief therapy. 43 short-term therapy as process of emotional learning. 181 Exploitation Index. 120 Eclecticism. 43 worldview of patient and sociocultural. and solution-focused brief therapy. 289 solution-focused brief therapy and emotional experiencing. 285. 282. 25.. Training cognitive therapy and. 290 Education. 284–285 Disqualifying or discounting of positive. 102. 30–31 about medications. 194–195. 108–109. and cognitive therapy. and interpersonal therapy. of treatment. 88. 8. 168. 5–6. and cognitive distortions. See also Psychoeducation. 37–38. 201. 282. 210–211. 250–251 Evaluation. See also Assessment of competence in brief therapy. 216–226 cognitive techniques and. 4 Emotional reasoning. 167 Experiences and experiential techniques cognitive-behavioral couple therapy and emotions. and integration of treatment approaches in psychotherapy. 36 Emotions. 8. 36 Duration. 170. 112–116 Eating disorders. See also Frequency of sessions. 94 .

35 Guided self-dialogue. 235. 90 Goals formulation of in brief therapy. behavior therapy and assessment of. Sigmund. 208 . 71–78 Exposure therapy. and interpersonal therapy. 258 Feedback cognitive therapy and. and solution-focused brief therapy. 33–34 Grief. as cognitive technique. as cognitive therapy technique. and solution-focused brief therapy. 120 Fear. 195. 4. John. 291 Functional comparisons of self. and cognitive therapy. for obsessive-compulsive disorder. 96 Frequency of sessions. 206. 162–164 orientation of cognitive therapy and. 111–112 Flowcharts. 61–62. 120 Guided behavior change. See also Duration Freud. as cognitive therapy technique. 27–28 solution-focused brief therapy and. and interpersonal therapy. See also Solution-focused brief therapy Formula first session task. 25 solution-focused brief therapy and setting of. and behavior therapy. 59–60 Guidelines. 286 new experiences and new understandings in timelimited dynamic psychotherapy as. and behavior therapy. fear of. 31 combined treatment and. 271 Goaling. 205. 66 cognitive therapy for panic disorder and. 55–56. 213–216 cognitive therapy and. See also Marriage and marital problems. 29–30 Gestalt empty-chair technique. 200–204 Guided discovery cognitive-behavioral couple therapy and. 183 Giving credit. 35 Global Evaluations of Trainee Change. 66 Focus. Parents and parenting cognitive-behavioral couple therapy and. and cognitive therapy. See also Loss Grinder. 56–57 299 Gender roles cognitive-behavioral couple therapy and. 147–148. for couple discussions. and cognitive-behavioral couple therapy. and role of therapist in cognitive-behavioral couple therapy. 104–112 Flying.Index Exposure and ritual prevention treatment program (EX/RP). 99–100 Graded exposure. and evaluation of competence in brief therapy. and definition of brief therapy. 195 interpersonal therapy and. in interpersonal therapy. 61–81 Facilitator. and solution-focused brief therapy. 246 Generalized anxiety disorder. 55–56. and cognitive-behavioral couple therapy. See also Emotions behavior therapy and. 42 Graded task assignments. 88 Group therapy. 274–275 Global rating forms. 199 Family. 35 Functioning. 138. 210 cultural issues and.

88 Harming obsessions. 189 . 150–153 problem areas in. 161 Intermediate sessions. cognitivebehavioral couple therapy and referrals for. 53–54. in interpersonal therapy. 189 Intensification. 267 Identity. 54 Hypothetical solutions. 58 Initial sessions. 88. 154 definition of. 18–19 Here-and-now terms. 70. 72–78. of stress inoculation training. 150–153 characteristics of. 27 completion of and prognosis for compliance with brief therapy. 149–150 Interpersonal perspective. as essential characteristic of brief therapy. Jay. and cognitive therapy. 7–9 Interactional countertransference. of timelimited dynamic psychotherapy. 159 Interpersonal techniques. 282 Interoceptive exposure. 222 Initial conceptualization phase. 222–226 Integrative behavioral couple therapy. and success of brief therapy. 107–108. 67. and indications for brief therapy and. and emotional interventions in cognitive-behavioral couple therapy. 199 cognitive therapy and. 109. and cognitive therapy. 238–239. 134–138 Intermittent therapy. 68 Interpersonal history. of interpersonal therapy. 141–144. 71. and cultural differences. cognitive. 251–252 Imagery work. 110 Identification. 79 Individual factors. 254. 132–134 In-session exposure. and behavior therapy. and solutionfocused brief therapy. 130–140 Haley. 6. for goals in solution-focused brief therapy. 140–147 theoretical framework of. and time-limited dynamic psychotherapy. 119 effectiveness of. 76–77 Helplessness. as cognitive technique. and treatment of obsessive-compulsive disorder. 290–291 of behavioral. See also Tasks behavior therapy and. 147–150 techniques and therapeutic process of. 122–124. 236. 89. 5. and obsessivecompulsive disorder. 125–127. 43 Interpersonal therapy (IPT) case examples of. See also Relationships Interpersonal issues. and behavior therapy. 100 Home visits. 26. of interpersonal therapy. 127–129 treatment methods in. 148.300 The Art and Science of Brief Psychotherapies Insomnia. 90 Integration of approaches to psychotherapy. 79 cognitive-behavioral couple therapy and. 192–194 Individual psychotherapy. 73 Homework. 120–127. and behavior therapy. in cognitivebehavioral couple therapy. 64–65 Insight-oriented couple therapy. and termination. 62–64. and solution-focused brief therapy. 143–147. 119–120 medication and. 135–137. 41 Imaginal exposure.

262 Mapping. 270. See also Grief interpersonal therapy and. 55 cognitive-behavioral couple therapy and. 201 Magnification/minimization. See also Culture Mutual engagement. 91–93. 291 Managed care. and solution-focused brief therapy. See also Cognitivebehavioral couple therapy. and schemas in cognitive theory. 26 Motivation. 130 Mood evaluation. 99–100. as cognitive distortion. 236 McMaster University (Canada). and combined treatment. 150–153. 273 Medication. 25. 37 Maintenance treatment. 72–78 Journal writing. and cognitive-behavioral couple therapy. and cognitive-behavioral couple therapy. and interpersonal therapy. 286 solution-focused brief therapy and. and interpersonal therapy. 104–112 301 Marriage and marital problems. Questions cultural issues in brief therapy and. and cognitivebehavioral couple therapy. time-limited dynamic psychotherapy and experiential. 107 Lankton. 165 Multicultural counseling. 116 Modes. as cognitive distortion. 100–101. and time-limited dynamic psychotherapy. 21–22 Mood disorders. 234 time-limited dynamic psychotherapy and. 197–198 cognitive therapy and structure of. 64–69. and success of brief therapy. 168 . 219 Mind reading. and interpersonal therapy. as cognitive distortion. 138–139 Love days. 25–28 In vivo exposure. Steven. 37 Metaphors behavior therapy and. 205 Loss. 194 Narrative. 281 formulation of goals and. and cognitive therapy. 88 Learning. and couple therapy. 108. 218.Index Interviews behavior therapy and structured clinical. Conversations. Couple therapy. as cognitive distortion. See also Communication. Relationships Mastery. 36 Language. 54–55 cognitive-behavioral couple therapy and. See also Education Listening. 217–220 Miracle question. 147–148 termination of therapy and. of patients success of brief therapy and. See also Combined treatment Mental filter. 109 Labeling. 139–140. and behavior therapy. and solution-focused brief therapy. and solutionfocused brief therapy. 162–163. and solution-focused brief therapy. and solution-focused brief therapy. 37 Minimized emotions. 283.

53. 37 Panic attacks. 237–238 Planning. concept of. 198 Obsessive-compulsive disorder behavior therapy and. 19 Personalization. 30–31 Parents and parenting. 121 Negative emotion. 233–235. and evaluation of competence in brief therapy. 132 Pedophilia. 66–67. 158–159 Observation. as cognitive distortion. 68 cognitive therapy for. 4 interpersonal therapy and. and combined treatment. 270. 220 Negative outcomes. 164 Number of sessions. 259. and timelimited dynamic psychotherapy. and definition of brief therapy. 4 successful brief therapy and. Family as analogy for solution-focused brief therapy. See also Therapist-patient relationship assessment of ability and willingness to benefit from brief therapy. 3 Oral examination. 42 combined treatment and. See also Agoraphobia behavior therapy and. 263 effectiveness of brief therapy for. 260–262 Placebo effect. 287–288 Postpartum depression. and couple therapy. 130 negative beliefs and. and evaluation of competence in brief therapy. and time-limited dynamic psychotherapy. 220 Positive form. See also Duration cognitive-behavioral couple therapy and.302 The Art and Science of Brief Psychotherapies Patient. 70 cognitive therapy and. 55–56. 246–248. 199–200 definition of brief therapy and. and interpersonal therapy. 240 New relational experience. See also Treatment plan Portfolio. 37 Physicians. in brief therapy. 271–272. 67. and cognitivebehavioral couple therapy. 6 culture and worldview of. 160 Pathogenesis. 190. and couple therapy. in brief therapy. 250–251 goals of solution-focused brief therapy and. and collaboration in combined treatment. 70 Performance deficit. and obsessive-compulsive disorder. 209 time-limited dynamic psychotherapy and. 240 suitability of for interpersonal therapy. 4. 270. 56–57. 204 Personality disorders interpersonal therapy and. 63–64. of goals in solutionfocused brief therapy. 123 Object relations. and cognitivebehavioral couple therapy. 87–88 cognitive-behavioral couple therapy and. 237 . 99 in vivo exposure and risk to. as cognitive distortion. 69. See also Children. 99 Positive traumas. 165–166 selection of and definition of brief therapy. 68–69 selection criteria for time-limited dynamic psychotherapy and. 258 Panic disorder. 274–275 Positive emotion. 273–274 Overgeneralization. 120.

69. 17–22 Psychosis. See also Couple therapy. and solution-focused brief therapy. Interpersonal history. 131. 100–102. See also Socratic questioning Racism. and couple therapy. 78–81 Present-focused character. 246. 28 interpersonal therapy and. 67–68. 106. 127–128 combined treatment and triadic. 158 PTSD Symptom Scale. 193–194 Primary emotions. 121–123. compared with interpersonal therapy. 78–81 Psychoanalytically oriented psychotherapy. Support network. 222 combined treatment and. 199 cognitive therapy and. 139 Relationships. of medications. Family. 106. of behavior therapy. See also Education behavior therapy and. 116. 121 Psychoanalytic Therapy: Principles and Applications (Alexander and French 1946). 219 Problem-focused nature. and couple therapy. 25. 149. Therapist-patient relationship attachment theory and. 260. 16. See also Consultation cognitive-behavioral couple therapy and. 259–260 Psychopathology. 53 cognitive-behavioral couple therapy and. 159–162. 21 Primary distress. 33 interpersonal therapy and. and evaluation of competence in brief therapy. 108 Rating scales.Index Posttraumatic stress disorder (PTSD). 135 Process affect. 280 time-limited dynamic psychotherapy and. Marriage and marital problems. 62–63. 59 cognitive therapy and. 52. and combined treatment. See also Timelimited dynamic psychotherapy Psychoeducation. 262. 154 time-limited dynamic psychotherapy and. and integration of treatment methods. 250 Questions. 59 Prolonged exposure (PE) treatment program. of behavior therapy. 100 Presession change. 165–166 Relaxation training behavior therapy and. 182 303 Psychological meaning. 271 Referrals. 53 Present-day terms. and solutionfocused brief therapy. 261 Psychotherapy in a New Key: A Guide to Time-Limited Dynamic Psychotherapy (Strupp and Binder 1984). 104–105. 116 Primal schemas. and behavior therapy. 261–262 Relapse cognitive therapy and. 163–164 Psychodynamic approach. for goals in solutionfocused brief therapy. 148. cognitive model of. 218. 53 Problem solving behavior therapy and. 34 skills in brief therapy and. 59 cognitive therapy and. 42 . and cultural issues. 98–99. and solution-focused brief therapy. 239. 144 Progressive muscle relaxation training. for posttraumatic stress disorder. 30. 263 interpersonal therapy and. 109. 55 Puerto Rico. 55.

67. 65. 190. and cognitivebehavioral couple therapy. 212–213. 66 Role transitions. and combined treatment. 106 Severity. 218–219 Safety behaviors. for goals in solutionfocused brief therapy. of multicultural clinical competence. 210–211 Self. and psychoeducation. 253 Self-help books. 78 Role-playing. and assessment of clinical performance. 31 Scaling questions. 93–94 effectiveness of. 69 cognitive therapy and. in time-limited dynamic psychotherapy. 72. 32 Socratic questioning. 239 Research. 100 Splitting. 204 Social context. 31 Specific terms. 105. 60. and in vivo exposure for obsessive-compulsive disorder. 106. See also Themes Schizophrenia. 73 Should and must statements. and couple therapy. 204–209 Skill deficit. See Relationships. in cognitivebehavioral couple therapy. 109 Skill-based interventions. 57 solution-focused brief therapy and. 75–76. 112–116 description of. See also Gender roles Safe environment. 42 Restricted emotions. 5 Sexuality. See also Brief therapy case examples of. 87–93 duration of. 34 . 148–149. and cognitive distortions. 234–235. and obsessive-compulsive disorder. and time-limited dynamic psychotherapy. 199. and cognitive therapy. and couple therapy. and cognitive therapy. 37 Simulations. and solutionfocused brief therapy. Support networks Social phobia. 116 Schemas. in solution-focused brief therapy. as cognitive technique. 33 Secondary distress. and interpersonal therapy. 35 Solution-focused brief therapy (SFBT). 91–93. 55. 97–112 Specific phobia behavior therapy and. 181 Response prevention. 55. 218 Secure attachment. 173–174 Resistance interpersonal therapy and. 214 cognitive therapy and. and behavior therapy. 66. and cognitive theory. 127–128 Selective attention. and cognitive therapy. 193–194 Secondary emotions. and cognitivebehavioral couple therapy. 73. See also Questions cognitive-behavioral couple therapy and. 272–273 Sine-wave charts. 167–168 Self-appraisal. of presenting problem and indications for brief therapy. 20–22. and cognitivebehavioral couple therapy. 217–220 Rituals. 101–102.304 The Art and Science of Brief Psychotherapies Self-report measures behavior therapy and. 95–97 practice of. 262 Stages of Change Model. 137–138 time-limited dynamic psychotherapy and.

170–171. Cognition. 5–6 interpersonal therapy and. 267. 248–252 skills in brief therapy and. Transference attachment and communication styles of. See also Automatic thoughts. 154 Tasks.Index Standards. 235–236 time-limited dynamic psychotherapy and. 198–200 worldview of and cultural issues. 205. of cultural groups. 131 skills in brief therapy and. 172. 289 success of brief therapy and. 138–139. Training. See also Therapist-patient relationship behavior therapy and. 69–70 role of in cognitive-behavioral couple therapy. 27 Supervision. 246 indications for brief therapy and. 130. See also Schemas cognitive-behavioral couple therapy and. 195 cultural issues and. 248–252 Thioridazine. 43 Support network. 272. 210–211. 147. 214–216 Stereotyping. 131. of cognitive therapy sessions. 260 Thoughts and thinking. 59 Suicide and suicidal behavior cognitive-behavioral couple therapy and. 287 solution-focused brief therapy and. 104. 291 of time-limited dynamic psychotherapy. 171. See also Therapeutic alliance behavior therapy and. 184 Themes. 235–237 Therapists. 208 cognitive therapy and. 168 Therapeutic alliance. 248 Stress and stressors. and cognitive therapy. 108–111 Termination. 54 cognitive therapy and. 132 as benevolent experts. 129. 150 Stress inoculation training (SIT). 54 cultural differences in. Valid thoughts cognitive-behavioral couple therapy and. Therapeutic alliance. 133 Therapist-patient relationship. 283. 221 cognitive therapy for depression and. See also Countertransference. 282 of interpersonal therapy. 274 Supportive techniques. See also Relationships cognitive-behavioral couple therapy and. See also Homework as focus of brief therapy. 150. 23 interpersonal therapy and. 191. and cognitive-behavioral couple therapy. 58–61 Structured problem solving. 280 in vivo exposure and risk to. 280–283. 195–196 305 time-limited dynamic psychotherapy and. 280–283 success of brief therapy and. for interpersonal therapy. 122. of treatment intermittent therapy and. Therapist-patient relationship. 178–179 Therapeutic frame. 147. 121. interpersonal problems and psychosocial. and training in brief therapy. 37–38 360-degree evaluation instrument. 275 . 28 Summarization.

306 The Art and Science of Brief Psychotherapies Trauma change agency skills in brief therapy and. 287–288 combined treatment and. 169 Vanderbilt University. 248. 168. and training in brief therapy. 159–162 case examples of. 184 theoretical framework of. 174–184 course of treatment in. 175–176 University of Missouri. 164. 262. 267 Videotapes. of therapists. 250 VA Short-Term Psychotherapy Research Project (VAST Project). 43 interpersonal therapy and. 281 Time limit. 165–166 research on. See also Education cultural issues and. See also Planning Treatment rationale. 86–87 time-limited dynamic psychotherapy and. and conflicts between worldviews of therapists and patients. and cognitive therapy. 54 Triadic relationships. and combined treatment. 273. 250–251 Vanderbilt Strategies Scale. See Center for the Treatment and Study of Anxiety Upstate Medical University (New York). and success of brief therapy. and behavior therapy. 124–127. and necessary skills for brief therapy. 169–170 training of therapists in. 171–172 Time-Limited Dynamic Psychotherapy: A Guide to Clinical Practice (Levenson 1995). 175–176 goals of. and combined treatment. 2 Valid thoughts. 145–147 time-limited dynamic psychotherapy and. 158 Timing. 252–253 learning skills of brief therapy and. 274 University of Pennsylvania. 123–124. 171–172 Time constraints. 170. of interpersonal therapy. 158–159 therapeutic strategies of. 41 Values. 166–169. 234 Training. 140. 170–171. 158 formulation and. 9–10. 258 Treatment plan. as cognitive distortion. 262. 173–174 termination of. 37 Understanding indications for brief therapy and. 168. on learning of skills in brief therapy. 171–172 Transference. 260 Tunnel vision. 263 Trifluoperazine. 173 Variability of problems and solutions in solution-focused brief therapy. 173–174 Verbal interventions. 161. 101–102 within cultural groups. See also Therapistpatient relationship cognitive therapy and. 5 time-limited dynamic psychotherapy and new. 236 . 178 success of brief therapy and interpretations of. See also Duration Time-limited dynamic psychotherapy (TLDP) assumptions essential to. 176–184 definition of. 162–164 inclusion and exclusion criteria for. 38. 159.

as cognitive technique. 55 .Index Weighing advantages/disadvantages. 270. 29–30 307 Written examination. and generalized anxiety disorder. 246–252 Worry. 274 Worldview. 268. 273 Yale-Brown Obsessive Compulsive Scale. and evaluation of competence in brief therapy. 41 Working Alliance Inventory. and cultural issues.

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